Lead toxicity associated with a gunshot-induced femoral fracture. A case report

Ballistic long bone fracture pattern: an experimental study

When dealing with badly preserved cadavers or skeletal human remains, the assessment of death circumstances remains challenging. When forensic evidence cannot be taken from the skin and soft tissue, the information may only be deduced from more resistant elements such as bone. Compared to cranial gunshot injuries, reliable data on ballistic long bone trauma remains scarce. This study aims to define ballistic fracture characteristics in human long bones. The shaft of 16 femurs and 13 humeri from body donors was perpendicularly shot with a 9-mm Luger full metal jacket bullet at an impact velocity of 360 m/s from a distance of 2 m. Some bones were embedded in Clear Ballistics Gel®, and some were shot without soft tissue simulant in order to better visualise the fracture propagation on the high-speed camera. The fractures were examined macroscopically and compared between the sample groups. We consistently found comminuted fractures with a stellate pattern. Fracture details were classified into entrance, exit and general characteristics. For some traits, we detected different occurrence values in the group comparison. The results indicate that some of the traits depend on bone properties such as shaft diameter, bone length and cortical thickness. The presence of ballistic gel also influenced some fracture traits, emphasising the relevance of soft tissue simulant in osseous gunshot experiments. This study revealed new insights in the detailed fracture pattern of human long bones. These may serve as guidelines for the identification and reconstruction of gunshot trauma in human long bones.

Infectious profiles in civilian gunshot associated long bone fractures

PURPOSE

There is a paucity of literature on infections in civilian gunshot associated with long bone fractures with the reported rates ranging from 0-15.7%.This study aimed to investigate the rates of infection associated with long bone fractures caused by civilian gunshots. The specific objectives were to determine if certain extremities were at a higher risk for infection and to identify the types of bacteria present in these infections by analyzing culture isolates.

METHODS

We conducted a retrospective review of consecutive patients aged 18-64 who sustained gunshot-associated long bone fractures at an urban Level I trauma centre from 2010 to 2017. Patient selection was based done through a institutional trauma centre database using international classification of diseases (ICD) 9 and 10 codes. We included patients who underwent surgical treatment, specifically fracture fixation, at our institution and excluded patients with fractures involving the pelvis, spine, foot, and hand. A total of 384 gunshot-associated long bone fractures in 347 patients were identified for analysis. Relevant patient-, injury-, and treatment-related variables were extracted from clinical records and radiographic reviews. Outcomes of interest included bony union, repeat operative procedures, and the development of deep infection.

RESULTS

347 patients with 384 long bone fractures were included. 32 fractures in 32 patients developed an infection for an incidence of 9.3% of patients and 8.3% of fractures. Gram-positive bacteria were present in 23/32 (72.0%) culture isolates, gram-negative bacteria in 10/32 (31.3%) culture isolates, and six infections were polymicrobial. Staphylococcus 16/32 (50.0%) and Enterobacter 6/32 (18.8%) species were the most common isolates. Of the Staphylococcus species, 5/16 (31.3%) were MRSA. Lower extremity fractures had a greater risk for infection compared to the upper extremity (11.7% vs 3.7% p < 0.01) and fractures that developed an infection had a larger average zone of comminution (63.9 mm vs 48.5 mm p < 0.05).

CONCLUSION

This study investigated the rates of infection associated with long bone fractures caused by civilian gunshots. The overall infection rate observed in our series aligns with existing literature. Gram-positive bacteria were the predominant isolates, with a notable incidence of MRSA in our patient population, highlighting the need for considering empiric coverage. Additionally, gram-negative organisms were found in a significant proportion of infections, and a notable percentage of infections were polymicrobial. Our findings emphasize the importance of carefully assessing highly comminuted lower extremity fractures and implementing appropriate antibiotic coverage and operative debridement for patients with gunshot-related long bone fractures. While current prophylaxis algorithms for open fractures lack specific inclusion of gunshot wounds, we propose incorporating these injuries to reduce the incidence of infections associated with such fractures.

Curcumin-loaded cockle shell-derived calcium carbonate nanoparticles ameliorates lead-induced neurotoxicity in rats via attenuation of oxidative stress

A substantial global health burden is associated with neurotoxicity caused by lead (Pb) exposure and the common mechanism of this toxicity is mainly via oxidative damage. Curcumin has remarkable pharmacological activities but remains clinically constrained due to its poor bioavailability when orally administered. Currently, cockle shell-derived calcium carbonate nanoparticle (CSCaCO3NP) is gaining more acceptance in nanomedicine as a nanocarrier to various therapeutics. This study aimed at investigating the ameliorative effect of curcumin-loaded CSCaCO3NP (Cur-CSCaCO3NP) on lead-induced neurotoxicity in rats. A total of 36 male Sprague-Dawley rats were randomly assigned into five groups. Each group consists of 6 rats apart from the control group which consists of 12 rats. During the 4 weeks induction phase, all rats received a flat dose of 50 mg/kg of lead while the control group received normal saline. The treatment phase lasted for 4 weeks, and all rats received various doses of treatments as follows: group C (Cur 100) received 100 mg/kg of curcumin, group D (Cur-CSCaCO3NP 50) received 50 mg/kg of Cur-CSCaCO3NP, and group E (Cur-CSCaCO3NP 100) received 100 mg/kg of Cur-CSCaCO3NP. The motor function test was carried out using the horizontal bar method. The cerebral and cerebellar oxidative biomarker levels were estimated using ELISA and enzyme assay kits. Lead-administered rats revealed a significant decrease in motor scores and SOD activities with a resultant increase in MDA levels. Furthermore, marked cellular death of the cerebral and cerebellar cortex was observed. Conversely, treatment with Cur-CSCaCO3NP demonstrated enhanced ameliorative effects when compared with free curcumin treatment by significantly reversing the aforementioned alterations caused by lead. Thus, CSCaCO3NP enhanced the efficacy of curcumin by ameliorating the lead-induced neurotoxicity via enhanced attenuation of oxidative stress.

Retained bullets and lead toxicity: a systematic review

INTRODUCTION

Lead toxicity secondary to retained bullet(s) (RB) after a penetrating gunshot wound is a rare but likely underdiagnosed condition, given the substantial number of firearm injuries in the United States. There is currently no consensus on the indications for surveillance, chelation, or surgical intervention.

OBJECTIVE

The purpose of our review is to summarize the literature on systemic lead toxicity secondary to RBs to help guide clinicians in the management of these patients.

METHODOLOGY

The primary literature search was conducted in Medline (PubMed), EMBASE, Cochrane, and CENTRAL using the following MESH terms: "chelation" and "lead poisoning" or "lead toxicity" or "lead" and "bullet" or "missile" or "gunshot", or "bullet".

RESULTS

The search identified 1,082 articles. After exclusions, a total of 142 articles were included in our final review, the majority of which were case reports. Several factors appear to increase the risk of developing lead toxicity including the location of the RB, the presence of a fracture or recent trauma, number of fragments, hypermetabolic states, and bullet retention duration. Particularly, RBs located within a body fluid compartment like an intra-articular space appear to be at a substantially higher risk of developing lead toxicity. Even though patients with lead toxicity from RBs will have similar symptoms to patients with lead toxicity from other sources, the diagnosis of lead poisoning may occur months or years after a gunshot wound. Symptomatic patients with high blood lead levels (BLLs) tended to improve with a combination of chelation and surgical removal of RBs.

CONCLUSIONS

We suggest surveillance with serial BLLs should be performed. Patients with intra-articular RBs appear to be at increased risk of lead toxicity and if possible, early surgical removal of the RBs is warranted, especially given that signs of toxicity are vague, and patients may not have access to follow-up. Long-term chelation should not be used as a surgical alternative and management should be multidisciplinary.

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.

Gunshot trauma in human long bones: towards practical diagnostic guidance for forensic anthropologists

In contrast to cranial gunshot trauma, diagnosis and interpretation of gunshot trauma to long bones remains difficult and controversial. The aim of this study is to review the published literature on fracture patterns resulting from gunshot trauma in human long bones, and to use the described characteristics to provide practical guidance for the forensic anthropologist. In order to achieve this, medical and forensic publications on this topic were reviewed. Several types of fractures, such as linear, oblique, comminuted and butterfly fractures, have been observed in either the shaft or the ends of long bones. Indirect fractures that are not caused by bullets striking bone directly but by bullet-induced forces to the surrounding soft tissue have been found as well. Some of these fractures are related to a specific context or mechanism which might help in the forensic reconstruction of events. It is recommended that future research should focus on available medical data to provide more detailed descriptions on fracture patterns for forensic purposes. Experimentation with bone surrogates and computer modelling might also provide better and more realistic reconstructions of gunshot trauma in the future and provide valuable insights for its diagnosis and interpretation in forensic anthropology.

From Molecular to Functional Effects of Different Environmental Lead Exposure Paradigms

Simple Summary

Our comparative study brings new insights regarding the effects of environmental lead exposure on the cardiorespiratory and nervous systems. We show how various kinds of exposure can lead to different toxicities, with various degrees of nefarious effects. The developmental period is of utmost importance to the toxicity of environmental lead; however, we found that the duration of exposure is the prime reason for stronger effects, even though the dual effect of intermittent exposure causes greater molecular neuronal alterations.

Abstract

Lead is a heavy metal whose widespread use has resulted in environmental contamination and significant health problems, particularly if the exposure occurs during developmental stages. It is a cumulative toxicant that affects multiple systems of the body, including the cardiovascular and nervous systems. Chronic lead exposure has been defined as a cause of behavioral changes, inflammation, hypertension, and autonomic dysfunction. However, different environmental lead exposure paradigms can occur, and the different effects of these have not been described in a broad comparative study. In the present study, rats of both sexes were exposed to water containing lead acetate (0.2% w/v), from the fetal period until adulthood. Developmental Pb-exposed (DevPb) pups were exposed to lead until 12 weeks of age (n = 13); intermittent Pb exposure (IntPb) pups drank leaded water until 12 weeks of age, tap water until 20 weeks, and leaded water for a second time from 20 to 28 weeks of age (n = 14); and the permanent (PerPb) exposure group were exposed to lead until 28 weeks of age (n = 14). A control group (without exposure, Ctrl), matched in age and sex was used. After exposure protocols, at 28 weeks of age, behavioral tests were performed for assessment of anxiety (elevated plus maze test), locomotor activity (open-field test), and memory (novel object recognition test). Metabolic parameters were evaluated for 24 h, and the acute experiment was carried out. Blood pressure (BP), electrocardiogram, and heart (HR) and respiratory (RF) rates were recorded. Baroreflex gain, chemoreflex sensitivity, and sympathovagal balance were calculated. Immunohistochemistry protocol for NeuN, Syn, Iba-1, and GFAP staining was performed. All Pb-exposed groups showed hypertension, concomitant with a decrease in baroreflex gain and chemoreceptor hypersensitivity, without significant changes in HR and RF. Long-term memory impairment associated with reactive astrogliosis and microgliosis in the dentate gyrus of the hippocampus, indicating the presence of neuroinflammation, was also observed. However, these alterations seemed to reverse after lead abstinence for a certain period (DevPb) and were enhanced when a second exposure occurred (IntPb), along with a synaptic loss. These results suggest that the duration of Pb exposure is more relevant than the timing of exposure, since the PerPb group presented more pronounced effects and a significant increase in the LF and HF bands and anxiety levels. In summary, this is the first study with the characterization and comparison of physiological, autonomic, behavioral, and molecular changes caused by different low-level environmental lead exposures, from the fetal period to adulthood, where the duration of exposure was the main factor for stronger adverse effects. These kinds of studies are of immense importance, showing the importance of the surrounding environment in health from childhood until adulthood, leading to the creation of new policies for toxicant usage control.

A systematic review of clinical and laboratory findings of lead poisoning: lessons from case reports

Lead is one of the most toxic heavy metals in the environment. The present review aimed to highlight hazardous pollution sources, management, and review symptoms of lead poisonings in various parts of the world. The present study summarized the information available from case reports and case series studies from 2009 to March 2020 on the lead pollution sources and clinical symptoms. All are along with detoxification methods in infants, children, and adults. Our literature compilation includes results from 126 studies on lead poisoning. We found that traditional medication, occupational exposure, and substance abuse are as common as previously reported sources of lead exposure for children and adults. Ayurvedic medications and gunshot wounds have been identified as the most common source of exposure in the United States. However, opium and occupational exposure to the batteries were primarily seen in Iran and India. Furthermore, neurological, gastrointestinal, and hematological disorders were the most frequently occurring symptoms in lead-poisoned patients. As for therapeutic strategies, our findings confirm the safety and efficacy of chelating agents, even for infants. Our results suggest that treatment with chelating agents combined with the prevention of environmental exposure may be an excellent strategy to reduce the rate of lead poisoning. Besides, more clinical studies and long-term follow-ups are necessary to address all questions about lead poisoning management.

High Velocity Gunshot Fractures of Humerus: Results of Primary Plate Osteosynthesis

BACKGROUND

High velocity gunshot fractures usually seen in conflict zones, often mandate external fixation due to delayed presentation and associated contamination. In the presented observational study, we managed high velocity gunshot fractures of humerus with adequate debridement and primary plate osteosynthesis under controlled conditions with gratifying results.

MATERIAL AND METHODS

Eighteen consecutive cases of fracture of the humerus secondary to high velocity gunshot wounds with ages ranging from 28 to 45 years reporting within 6 h of the initial injury formed our study group. Immediate debridement, lavage and primary plate osteosynthesis was carried out following hemodynamic stabilisation and intravenous antibiotics. All the cases were followed up at 2, 4, 6 months, 1 year and then annual follow-up including telephonic follow-up for six patients.

RESULTS

Fifteen cases of Gustillo Anderson type III A, two of type III B and one of type III C were managed with primary plate osteosynthesis. Brachial artery injury was addressed immediately, however injured radial nerve ends were tagged. Five cases showed delayed/non-union and were managed with decortication and autologous bone grafting. Two cases of deep infection could be managed with implant retention till union. The implants were removed following fracture consolidation. All the fractures united and no patient was left with sequelae of chronic infection.

CONCLUSION

Timely presentation of high velocity gunshot fractures of humerus teamed up with adequate debridement, soft tissue management and primary plate osteosynthesis can offer satisfactory outcomes. Associated vascular injury needs immediate attention. Nerve injuries can be addressed in a staged procedure. Our results have been satisfactory and add to the scant literature available on the subject, however further studies are warranted.

Treatment of secondary hip arthritis from shell fragment and gunshot injury in the Syrian civil war

Background

In gunshot and shell fragment injuries to the hip joint, orthopedic intervention includes wound assessment and care, osteosynthesis of fractures, and avoiding of infection and osteoarthritis. Individuals injured in the Syrian civil war were frequently transferred to the authors’ institution in neighboring city. Orthopedic trauma exposures were determined in approximately 30% of these patients. The aim of this study was to evaluate the outcomes of the patients with secondary hip arthritis due to prior gunshot and shell fragment (shrapnel) injuries who underwent primary total hip arthroplasty.

Methods

This retrospective study reviewed 26 patients (24 males, 2 females) who underwent hip arthroplasty due to prior gunshot and shell fragment injuries from November 2013 to January 2019. For all patients, the Harris Hip Score (HHS) was evaluated preoperatively and after surgery.

Results

Mean age was 31.5 (range, 19–48) years. The mean preoperative HHS was 52.95 points, and the mean postoperative HHS was 79.92 points at the final follow-up after surgery. Patients with shell fragment injuries to the hip joint had higher infection rates, but it is not statistically significant.

Conclusions

An anatomic reduction of the fracture may not be possible in these cases as a result of significant bone and/or cartilage loss. Total hip arthroplasty can be done after gunshot- and shell fragment-related posttraumatic arthritis. It is an effective treatment choice to reduce pain and improve function, but the surgeon must be very careful because of high rate of infection.

Injury and treatment patterns of ballistic pelvic fractures by anatomic location

INTRODUCTION

Pelvic ballistic injuries threaten critical gastrointestinal, vascular, and urinary structures. We report the treatment patterns and injury profiles of ballistic pelvic fractures and the association between location of ballistic fractures of the pelvis and visceral injuries.

METHODS

A prospectively collected database at an academic level I trauma center was reviewed for clinical and radiographic data on patients who sustained one or more ballistic fractures of the pelvis. Main outcomes compared included: procedures with orthopedic surgery, emergent surgery, concomitant intrapelvic injuries, and mortality.

RESULTS

Eighty-six patients were included. Eight patients (9.3%) underwent surgical debridement with orthopedic surgery, no ballistic pelvic fractures required surgical stabilization. The anatomical locations of ballistic pelvic fractures included: 10 (14.7%) anterior ring, 13 (19.1%) posterior ring, 27 (39.7%) anterior column, and 18 (20.9%) posterior column. There was a statistically significant association between anterior ring and rectal injury. The association between anterior ring injury and bladder injury approached significance.

CONCLUSIONS

This case series included 86 patients with a ballistic fracture of the pelvis, none requiring pelvic ring surgical stabilization. The unpatterned behavior of these injuries demands a high suspicion for visceral injury, with special attention to the rectum and bladder in the setting of anterior ring involvement.

LEVEL OF EVIDENCE

IV.

Extremity Firearm Trauma: The Impact of Injury Pattern on Clinical Outcomes

As a group, the extremities are the most commonly injured anatomic region in nonfatal firearm trauma and are associated with high rates of vascular and bony injury. This study examines the epidemiology, incidence and distribution of firearm-related extremity trauma and the relationship between injury pattern and local or systemic complications. Review of the National Trauma Databank identified 6987 patients with isolated extremity firearm injury. Epidemiologic data, injury pattern incidence, and local and systemic complications were reviewed. Multivariate analysis identified the impact of extremity injury pattern on complications. Overall fracture incidence was 22 per cent. Fracture was associated with both vascular (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.5 to 2.4; P < 0.001) and nerve injury (OR, 2.6; 95% CI, 1.9 to 3.5; P < 0.001). Isolated fracture increased risk of compartment syndrome (OR, 2.4; 95% CI, 1.1 to 5.3; P = 0.035). Vascular injury alone increased the risk of compartment syndrome (OR, 11.5; 95% CI, 5.0 to 26.2; P < 0.001) and deep venous thrombosis (OR, 7.9; 95% CI, 2.5 to 25.2; P < 0.001). Fracture and vascular injury together also increased risk of wound infection (OR, 9.7; 95% CI, 3.9 to 23.4; P < 0.001). In patients with extremity trauma, the injury pattern significantly impacts local but not systemic complication rates. Gunshot-related fracture, occurring in one-fifth of patients, increases the risk of vascular and nerve injury. Vascular injury, with or without fracture, is the biggest predictor of local complications.

Do Battlefield Injury-acquired Indwelling Metal Fragments Induce Metal Immunogenicity?

BACKGROUND

A battlefield-related injury results in increased local and systemic innate immune inflammatory responses, resulting in wound-specific complications and an increased incidence of osteoarthritis. However, little is known about whether severe injuries affect long-term systemic homeostasis, for example, immune function. Moreover, it also remains unknown whether battlefield-acquired metal fragments retained over the long term result in residual systemic effects such as altered immune reactivity to metals.

QUESTIONS/PURPOSES

Does a retained metal fragment from a battlefield injury contribute to increased (1) adaptive metal-specific immune responses, (2) systemically elevated metal ion serum levels, and (3) serum immunoglobulin levels compared with combat injuries that did not result in a retained metal fragment?

METHODS

In this pilot study, we analyzed metal-immunogenicity in injured military personnel and noninjured control participants using lymphocyte transformation testing (LTT, lymphocyte proliferation responses to cobalt, chromium and nickel challenge at 0.001, 0.01 and 0.1-mM concentrations in triplicate for each participant), serum metal ion analysis (ICP-mass spectroscopy), and serum immunoglobulin analysis (IgE, IgG, IgA, and IgM ). Military personnel with a battlefield-sustained injury self-recruited without any exclusion for sex, age, degree of injury. Those with battlefield injury resulting in retained metal fragments (INJ-FRAG, n = 20 male, mean time since injury ± SD was 12 ± 10 years) were compared with those with a battlefield injury but without retained metal fragments (INJ-NO-FRAG, n = 12 male, mean time since injury ± SD was 13 ± 12 years). A control group comprised of male noninjured participants was used to compare measured immunogenicity metrics (n = 11, males were selected to match battlefield injury group demographics).

RESULTS

Military participants with sustained metal fragments had increased levels of metal-induced lymphocyte responses. The lymphocyte stimulation index among military participants with metal fragments was higher than in those with nonretained metal fragments (stimulation index = 4.2 ± 6.0 versus stimulation index = 2.1 ± 1.2 (mean difference 2.1 ± 1.4 [95% confidence interval 5.1 to 0.8]; p = 0.07) and an average stimulation index = 2 ± 1 in noninjured controls. Four of 20 participants injured with retained fragments had a lymphocyte proliferation index greater than 2 to cobalt compared with 0 in the group without a retained metal fragment or 0 in the control participants. However, with the numbers available, military personnel with retained metal fragments did not have higher serum metal ion levels than military participants without retained metal fragment-related injuries or control participants. Military personnel with retained metal fragments had lower serum immunoglobulin levels (IgG, IgA, and IgM) than military personnel without retained metal fragments and noninjured controls, except for IgE. Individuals who were metal-reactive positive (that is, a stimulation index > 2) with retained metal fragments had higher median IgE serum levels than participants who metal-reactive with nonmetal injuries (1198 ± 383 IU/mL versus 171 ± 67 IU/mL, mean difference 1027 ± 477 IU/mL [95% CI 2029 to 25]; p = 0.02).

CONCLUSIONS

We found that males with retained metal fragments after a battlefield-related injury had altered adaptive immune responses compared with battlefield-injured military personnel without indwelling metal fragments. Military participants with a retained metal fragment had an increased proportion of group members and increased average lymphocyte reactivity to common implant metals such as nickel and cobalt. Further studies are needed to determine a causal association between exposure to amounts of retained metal fragments, type of injury, personnel demographics and general immune function/reactivity that may affect personal health or future metal implant performance.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Persistent Effects on Cardiorespiratory and Nervous Systems Induced by Long-Term Lead Exposure: Results from a Longitudinal Study

Long-term lead (Pb) exposure alters the normal development of the nervous system and physiology. It affects multiple organ systems, causing hypertension, cardiorespiratory dysfunction, being a well-known neurotoxin, inducing changes in neurogenesis, neurodegeneration, and glial cells. However, studies of the developmental effects of lead and its outcomes throughout life are lacking. Determine morphofunctional, behavioral, and cognitive developmental effects of long-term lead exposure at three different ages. Wistar rats were exposed to a Pb-acetate solution from fetal period until adulthood and compared to a non-exposed control group. General behavior and cognitive skills were evaluated by behavioral tests and physiological data and cardiorespiratory reflexes measured. Neurodegeneration, neuroinflammation, and synaptic activity were assessed by immunohistochemistry. Lead exposure caused long-lasting anxiety-like behavior and strong long-term memory impairment without changes in locomotor and exploratory activity. Hypertension was observed at all time points, concomitant with baroreflex impairment and increased chemoreflex sensitivity. Persistent neuroinflammation, transient synaptic overexcitation without neurodegeneration was observed. Long-term Pb exposure, since fetal period, causes long-lasting anxiety-like behavior, concomitant with hypertension, without general motor skills impairment. Synaptic overexcitation, reactive astrogliosis, and microgliosis could underlie behavioral and long-term memory changes, which might have been caused during developmental phases and consolidated during adulthood. Also, alterations observed in the cardiorespiratory reflexes can explain persistent hypertension. This longitudinal study identifies and characterizes lead toxicity nature and magnitude, important to devise and test potential interventions to attenuate the long-term harmful effects of lead on the nervous and cardiovascular systems.

Gunshot Wounds to the Upper Extremity

Upper extremity gunshot wounds result in notable morbidity for the orthopaedic trauma patient. Critical neurovascular structures are particularly at risk. The fractures are often comminuted and may be associated with a variable degree of soft-tissue injury. The literature lacks consensus regarding antibiotic selection and duration, and indications for surgical débridement. Bullets and/or bullet fragments should be removed in cases of plumbism, intra-articular location, nerve impingement, location within a vessel, and location in a subcutaneous position within the hand and/or wrist. Gunshot fractures generally do not follow common fracture patterns seen in blunt injuries, and the complexity of certain gunshot fractures can often be a challenge for the treating orthopaedic surgeon. Common plate and screw constructs may not adequately stabilize these injuries, and innovative fixation techniques may be required. The treatment for bone defects varies by location and severity of injury, and typically requires staged treatment. Nerve injuries after gunshot wounds are common, but spontaneous nerve recovery is expected in most cases.

Retained Lumbar Bullet: A Case Report of Chronic Lead Toxicity and Review of the Literature

BACKGROUND

Lead toxicity from retained bullet fragments is difficult to both predict and diagnose, but important to treat early, given the potential severity of disease. Blood lead levels > 25 μg/dL and 40 μg/dL are considered toxic in children and adults, respectively. Symptoms may range from nonspecific constitutional symptoms to seizures and coma. Chelation is the mainstay therapy for lead poisoning and levels to treat depend on patient age, blood lead levels, and the presence of symptoms. CASE 

REPORT

We present the case of a woman with symptoms of severe lead toxicity from 20-year-old retained bullet fragments. She had been seen by multiple providers for evaluation of each symptom, but a unifying diagnosis had not been found. After identifying this complication, she was treated appropriately and more serious complications were prevented. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case to increase awareness among emergency physicians of lead toxicity in patients with a seemingly unrelated constellation of symptoms and a history of a previous gunshot wound with retained bullet or bullet fragments.

Surgical management principles of gunshot-related fractures

This article discusses contemporary management strategies for gunshot-related fractures with special attention paid to the initial evaluation, role of debridement, principles of fixation, need and duration of antibiotic therapy, and management of sequelae. Pertinent sequelae detailed are fractures associated with vascular injury, compartment syndrome, massive loss of soft tissue and bone, nerve injury, and lead toxicity.

Ultrasound imaging of embedded shrapnel facilitates diagnosis and management of myofascial pain syndrome

Trigger points can result from a variety of inciting events including muscle overuse, trauma, mechanical overload, and psychological stress. When the myofascial trigger points occur in cervical musculature, they have been known to cause headaches. Ultrasound imaging is being increasingly used for the diagnosis and interventional management of various painful conditions. A veteran was referred to the pain clinic for management of his severe headache following a gunshot wound to the neck with shrapnel embedded in the neck muscles a few years prior to presentation. He had no other comorbid conditions. Physical examination revealed a taut band in the neck. An ultrasound imaging of the neck over the taut band revealed the deformed shrapnel located within the levator scapulae muscle along with an associated trigger point in the same muscle. Ultrasound guided trigger point injection, followed by physical therapy resolved his symptoms. This is a unique report of embedded shrapnel and coexisting myofascial pain syndrome revealed by ultrasound imaging. The association between shrapnel and myofascial pain syndrome requires further investigation.