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Tintinalli's Emergency Medicine > Cha pte r e 263.1. W ound Ba llistics >

GENERAL CONCEPTS
Ballistic injury is associated with bullet velocity and mass, as w ell as other bullet and tissue
characteristics.1–3 Slow-moving bullets crush more tissue, and fast-moving bullets cause more
cavitation. Bullet mass, w hich is related to diameter and length, largely determines how deeply the
bullet w ill penetrate tissue. Bullet construction (such as w hether the bullet is solid lead with no bullet
jacket, is partially jacketed, or has a full metal jacket) largely determines if the bullet w ill deform or
fragment. Bullet shape and center of mass (w hich determine how soon it will yaw in its path through
tissue), the thickness of the body part wounded (determining whether the bullet has a long enough path
through tissue to deform or yaw; Figure 263.1-1), tissue type struck (e.g., femur vs. lung), tissue
elasticity, density, and internal cohesiveness [which determine how well the tissue will withstand tissue
stretch (temporary cavitation) forces] are all important factors in determining the nature of the wound
produced. The amount of kinetic energy "deposited" in a victim w ounded by a projectile is not a reliable
predictor of wound severity.4

Figure 263.1-1.

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C ompare two .22 caliber bullets. A. A .22 long-rifle round (left) and an M16 round (right). B,C. Wound profiles in
ballistic gelatin of the same .22 long-rifle (B) and .224 caliber M-193 round of the M16A1 rifle (C). [Full metal
case (FMC ) is a synonym for full metal jacket, the type of bullet used in the military.] This figure shows that
caliber (bullet diameter in decimals of an inch or in millimeters) is only one indicator of wounding potential and
not a very good one. Because of much higher velocity [3094 ft/s (943 m/s), as opposed to 1122 ft/s (342 m/s)
for the .22 long-rifle bullet], because it fragments in tissue, and because of greater bullet mass, the M16 bullet
has the potential to cause a much more severe wound if the anatomic part struck is sufficiently thick. Note that
in the gelatin block, both the permanent cavity and the temporary cavity caused by the M16 bullet are much
larger than those of the .22 long-rifle bullet. As is usual for a nondeforming bullet, the temporary and permanent
cavities caused by the .22 long-rifle bullet are largest when the bullet is at 90 degrees of yaw.

An understanding of wound ballistics enables physicians to evaluate and treat missile wounds
effectively. Based on common misconceptions about wound ballistics, some authors have suggested
unnecessary and possibly harmful treatment for gunshot wounds. An example of such a harmful
recommendation is that for mandatory surgical excision of the tissue surrounding the path of the
projectile through tissue w henever an extremity wound is caused by a "high-velocity" bullet. This is
based on the belief that these tissues will become necrotic. Clinical experience and research have
demonstrated this to be false.5

WOUNDING POTENTIAL
Every moving bullet has a maximum w ounding potential determined by its mass and velocity. Bullets of
equal w ounding potential may produce w ounds of very different type and severity, depending on bullet
shape, internal and external construction, and which tissues they traverse.

A heavier, slower bullet crushes more tissue but induces less temporary cavitation. Most of the
w ounding potential of a lighter, faster bullet is likely to be used up forming a larger temporary cavity,
but a fast bullet leaves a smaller permanent cavity (crushes less tissue).4,6 The larger, heavier, slower
bullet strikes more tissue and causes a more severe wound in elastic tissue than the lighter, faster
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bullet, which uses up much of its wounding potential producing tissue stretch (temporary cavitation).
This tissue stretch may be absorbed with little or no ill effect by elastic tissue such as lung or muscle. In
less elastic tissue, such as liver or brain, the temporary cavity can produce a more severe wound.
Penetration depth w ill usually be less with the lighter, faster bullet, and critical structures such as the
heart may not be reached.

MECHANISMS OF WOUNDING
Both missile and tissue characteristics determine the nature of the w ound. Missile characteristics are
partly inherent (mass, shape, and construction) and are partly conferred by the weapon (longitudinal
and rotational velocity). Tissue characteristics (elasticity, density, and anatomic relationships) also
strongly affect the nature of the wound. The severity of a bullet wound is influenced by the bullet's
orientation during its path through tissue and by whether the bullet fragments4 and deforms.

Two major mechanisms of w ounding occur: the crushing of the tissue struck by the projectile (forming
the permanent cavity) and the radial stretching of the projectile path walls (forming a temporary cavity;
Figure 263.1-1). In addition, a sonic pressure w ave precedes the projectile through tissue. The sonic
pressure w ave plays no part in w ounding.7

Crushing of Tissue
ANGLE OF ENTRY
A missile crushes the tissue it strikes, thereby creating a permanent wound channel (permanent
cavity). If the bullet is traveling with its pointed end forward and its long axis parallel to the longitudinal
axis of flight (0 degrees of yaw, the angle between the long axis of the bullet and its path of flight), it
crushes a tube of tissue approximately equal to its diameter. When the bullet yaws to 90 degrees, the
entire long axis of the bullet strikes tissue. The amount of tissue crushed may be three times greater at
90 degrees than at 0 degrees of yaw.

BULLET DEFORMATION
When striking soft tissue with sufficient velocity, soft-point and hollow-point bullets deform into a
mushroom shape. This increases surface area and the amount of tissue crushed. For most big-game
hunting, soft-point and hollow -point bullets are used to increase the probability of prompt lethality
rather than the creation of a nonlethal w ound causing an animal prolonged suffering. If the
mushroomed diameter is 2.5 times greater than the initial diameter of the bullet, the area of tissue
crushed by the bullet is 6.25 times greater than the amount that would have been crushed by the
undeformed bullet (the area encompassed by a circle is proportional to the circle's radius squared).

BULLET FRAGMENTATION
Bullet fragmentation also increases the volume of tissue crushed.1,4 After bullet fragmentation, bullet
surface area is increased, and much more tissue is crushed. Multiple perforations weaken tissue and
create focal points for stress (stress risers). Tissue tears are particularly likely to occur at stress risers
during temporary cavitation stretch.4 For large handgun (e.g., .44 Magnum) and rifle bullets, the
striking of bone causes early bullet fragmentation.

Comminuted fractures may be created by rifle and large handgun bullets striking bone. Bone fragments
can become secondary missiles and crush tissue. Many handgun bullets do not fragment bone
significantly. When a large bone is struck by a handgun bullet, it is likely that the bullet w ill expend its
w ounding potential in the victim and will not exit.

Bullet fragments and secondary missiles, such as bone fragments, teeth, or coins, propelled by contact
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w ith the bullet can increase the severity of the w ound.

BULLET JACKETS
Unjacketed lead bullets cannot be driven faster than about 2000 ft/s (610 m/s) w ithout some of the
lead stripping off in the barrel. Lead stripping is avoided if a jacket made of a harder metal (such as
copper or a copper alloy) is used to surround the lead. The jacket of a military bullet completely covers
the bullet tip (called a "full metal jacket").

HOLLOW-POINT AND SOFT-POINT BULLETS

Civilians often use hollow -point or soft-point bullets. Hollow-point bullets have a hole in the jacket at
the bullet tip, and soft-point bullets have some of the lead core of the bullet exposed at the bullet tip.
These constructions weaken the bullet tip, causing it to flatten on impact. Flattening often greatly
increases bullet diameter, resulting in a mushroom-shaped projectile.

The hollow-point and soft-point bullets used by civilians are more damaging to tissue than are full-
metal-jacketed military bullets that do not deform.1,4,8 Because of this, wounds produced by civilian
hunting rifles, and large-caliber handguns are usually more severe than w ounds produced by military-
rifle bullets of the same mass and velocity.8

Well-designed hollow-point and soft-point handgun bullets usually deform into a mushroom shape.
Poorly designed hollow-point and soft-point handgun bullets with an excessively stiff or thick bullet
jacket can fail to deform into a mushroom shape. Also, even w ell-designed bullets can fail to expand if
fired from distances (greater than a few hundred yards) at which their retained velocity is insufficient to
provide the striking force needed for bullet expansion.

When the tip of a hollow-point bullet is plugged w ith material such as clothing or drywall, bullet
expansion into a mushroom shape in tissue is usually delayed and sometimes prevented. This causes
deeper penetration of tissue, sometimes resulting in a perforating wound (having both an entrance
and an exit). This may result in the injury of bystanders.

BULLET VELOCITY AND FRAGMENTATION

Projectiles penetrate more deeply as projectile velocity is increased, but only up to the point at which
velocity becomes sufficiently high to deform the projectile. Penetration depth decreases markedly from
that point on. The greater the bullet diameter expansion from mushrooming, the less is the depth of
penetration.9

There is a critical range of velocity for each handgun hollow-point and soft-point bullet within which the
bullet may perform as expected. Below this velocity range, the bullet will have insufficient velocity to
mushroom on impact, and at velocities above this range, the bullet may fragment after impact, resulting
in many light bullet pieces crushing tissue at a superficial depth.

Military full metal jacket bullets do not flatten at the bullet tip (i.e., they do not mushroom). Sometimes,
they can break and fragment as a result of yaw ing to 90 degrees. The stress on the bullet as its long
axis strikes tissue causes the sides of the bullet to flatten as if the bullet had been squeezed in a vise.
If the bullet breaks, it usually w ill do so at the cannelure, a circular groove around the bullet w here it is
crimped into the cartridge case. Although the M-193 military bullet of the M16 rifle fragments in soft
tissue w ounds with a characteristic pattern depending on range,10 most other full metal jacket military
bullets, such as those fired from the AK-47, AK-74, and the NATO 7.62-mm rifle (U.S. version), do not
fragment unless they strike a large bone.

If a bullet is jacketed, the bullet jacket usually cannot be distinguished from the lead core on standard

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radiographs because the entire bullet is metallic density. Sometimes, however, as the bullet deforms or
fragments, the bullet jacket separates from the bullet and is identifiable on a radiograph. It is often
less dense than the bullet fragments and may have a distinctive shape.

In extremity w ounds, when a radiograph reveals an undeformed bullet lying in the soft tissues and no
fracture is present, tissue disruption is usually minor. If a major vessel or nerve is divided, how ever,
even a simple wound can have a severe effect on the patient. The location of the wound is the most
important factor. A bullet of low w ounding potential can cause a severe wound if it passes through a
vital structure, such as the spinal cord.

Temporary Cavitation (Tissue Stretch)

MECHANISM OF CAVITATION
Fired from an appropriate, well-designed weapon, a bullet flies in air w ith its nose pointed forward; it
yaw s only 1 to 3 degrees. Yaw occurs around the bullet's center of mass. In pointed rifle bullets, the
center of mass is behind the midpoint of the bullet's long axis. Although the bullet's most naturally
stable in-flight orientation w ould be w ith its heaviest part (its base) forward, for aerodynamically
efficient flight, it must fly point forward.

During flight, bullet yaw is prevented by the bullet's spin imparted to it by the spiral grooves (rifling) in
the gun barrel. The longer (and heavier) the bullet in relation to its diameter, the more rapidly it must
be rotated to avoid significant yaw in flight. A gun barrel intended to fire a heavier bullet has rifling that
makes a full turn in fewer inches of barrel length than the rifling in a barrel intended for a shorter,
lighter bullet of the same caliber. This will cause a faster rate of bullet spin.

A gun with a shorter barrel will impart to the bullet a lower velocity than would a w eapon with a longer
barrel when firing the same round. With shorter barrel length, the expanding gases of the burning
gunpowder have less time to accelerate the bullet before they are discharged into the atmosphere. A
.22 long-rifle round fired in a rifle may produce a bullet with up to 300 ft/s more velocity than w ould the
same round fired in a handgun.

Although the bullet's spin is adequate to stabilize it (prevent yaw) in its flight through air, it is not
adequate to stabilize it in its path through tissue because of the higher density of the medium. A
pointed bullet that does not deform eventually yaw s to a base-forw ard position (180 degrees of yaw).
Expanding bullets lose the physical stimulus to yaw because, after mushrooming, their heaviest part is
forward.

CAVITATION
As a bullet passes through 90 degrees of yaw , or after it deforms into a mushroom shape, it is crushing
its maximal amount of tissue. It is slowed down rapidly as its wounding potential is used up. The bullet
creates a splash-type force in tissue, which spreads out radially. This force creates the temporary
cavity. This aspect of the wounding process is analogous to the splash of a diver entering the water.

If a diver enters the water very straight and pointed forward (similar to a bullet at 0 degrees of yaw),
the splash is minimal. If the diver does a belly-flop (similar to a bullet at 90 degrees of yaw), a large
splash is induced. In tissue, this splash, the temporary cavity, can produce localized blunt trauma.6 The
temporary cavity reaches its maximum size several milliseconds after the bullet has passed through the
tissue. Because forces follow paths of least resistance, temporary cavitation can be asymmetric: it can
separate tissue planes.

The temporary cavity caused by common handgun bullets is generally too small to be a significant
w ounding factor in all but the most sensitive tissues (brain and liver). Center-fire rifle bullets and large

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handgun bullets (e.g., .44 Magnum) often induce a large temporary cavity [10- to 25-cm (4- to 10-in.)
diameter] in tissue. This can be a significant w ounding factor depending on the characteristics of the
tissue in w hich it forms.

Near-water density, less-elastic tissue (such as brain, liver, or spleen), fluid-filled organs (including the
heart, bladder, and GI tract), and dense tissue (such as bone) may be damaged severely when a large
temporary cavity displaces them or forms within them. More elastic tissue (such as skeletal muscle) and
lower-density elastic tissue (such as lung) are less affected by the formation of a temporary cavity.

Although the formation of a large temporary cavity often has highly disruptive effects in the brain or
liver, its effect in w ounds of the extremities frequently has been exaggerated.11 Fracture of large
bones not hit by the bullet and tearing of major vessels or nerves by the temporary cavity are
mentioned often in the literature but are rare in clinical experience. Most of the permanent damage
done in wounds of the extremities is the result of structures being hit by the intact bullet, bullet
fragments, or secondary missiles. As in all blunt trauma, shear forces develop and tear structures at
points where one side is fixed and the other side is free to move. The temporary cavity is no
exception.6 In the unlikely event that the blunt trauma caused by the temporary cavity tears a vessel
w all, this is particularly likely to occur at the vessel origin.

BALLISTIC PROPERTIES AND THE WOUND PRODUCED

The characteristics of the wounded tissue; the thickness of the body part; the point in the path of the
bullet at which deformation into a mushroom shape or yaw or fragmentation occurs; and other factors
strongly influence the w ound produced.

Animal experiments using military rifle bullets 5 have clearly disproved the assertion that all tissue
exposed to temporary cavitation is destroyed. Not only does the 14-cm-diameter temporary cavity
produced by an AK-74 bullet not destroy a great amount of muscle, but the sizable stellate exit wound
it causes in the uncomplicated thigh wound ensures excellent wound drainage, w hich assists healing.5
A history that the wound w as caused by a "high-velocity" bullet does not mandate radical excision of
the wound path.11

Bullet Yaw
Experiments with ballistic gelatin (which reproduces the projectile deformation and penetration depth
of living animal muscle) have shown that most full metal jacket rifle bullets yaw significantly only at
tissue depths greater than the diameter of human extremities.

In the first 12 cm (the average thickness of an adult human thigh) of a soft tissue w ound path, there is
often little or no difference between the w ounding effect of "low"- and "high"-velocity bullets when the
"high"-velocity bullet is of the military full metal jacket type. This is particularly true of the relatively
heavier military-rifle bullets such as those fired by the AK-47 and NATO 7.62-mm (U.S. version) rifle. A
w ound of an extremity caused by an AK-47 bullet that does not hit bone is often similar to a handgun
bullet w ound. No matter how "high" its velocity, if a nondeforming, heavy bullet does not break,
fragment, or hit a large bone, it w ill exit an extremity w ith much of its wounding potential unspent.
These same bullets can be lethal in chest or abdominal wounds because the trunk is thicker than an
extremity and allow s the bullet a sufficiently long path through tissue to become unstable and yaw .
Maximal temporary cavitation induced by the AK-47 bullet usually occurs at a tissue depth of 28 cm,
much greater than the diameter of a human extremity.

A soft-point or hollow-point bullet fired from a civilian center-fire rifle deforms soon after entering tissue
and produces a much more severe extremity wound than will a military full metal jacket bullet that does
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not break and fragment.

The more recently developed, smaller-caliber AK-74 fires a bullet that is lighter than the AK-47 bullet
and yaws earlier.12 Its maximal temporary cavity occurs at a tissue depth of 11 cm. Extremity wounds
from the AK-74 can be expected to be more severe than those from the AK-47.12 The lighter, smaller
AK-74 round allow s a soldier to carry many more rounds of ammunition. This was the primary
motivation for development of the M16 and the AK-74. An additional benefit is their light recoil, w hich
makes them easier to shoot accurately.

Caliber
A bullet's caliber (bullet diameter in decimals of an inch or in millimeters) is not a valid indicator of
w ounding potential. A bullet's mass, its structure, and its striking velocity are all significant
considerations that must be considered in determining a bullet's wounding potential.

Commonly used w eapon and bullet designations are often misleading. As an example, the .38 special
and the .357 Magnum use bullets that have the same diameter [.357 inches (9.07 mm)] (Table 263.1-
1). The longer cartridge case of the Magnum can hold more pow der, giving a bullet the potential for
higher velocity and greater wounding potential.

Table 263.1-1 Cartridge Case Name and Actual Bullet Diameter Used

Cartridge Cases Actual Bullet Cartridge Cases Actual Bullet

Diameter (inches) Diameter (inches)

Of common interest 240 Weatherby Magnum .243

32 Auto (ACP) .312 256 Winchester Magnum .257

380 Auto (ACP) .355 250/300 Savage .257

9-mm Luger (9-mm .355 257 Roberts .257
Parabellum)

38 Super .355 25/06 Remington .257

38 Special .357 257 Weatherby Magnum .257

357 Magnum .357 30-06 .308

44 Special .4295 30-30 Winchester .308

44 Magnum .4295 30 M1 Carbine .308

444 Marlin .4295 7.62-mm X 39-mm (AK-47) .308

Others of interest 30/40 Krag .308

22 Hornet .223 and .224 7.5-mm X 55-mm Swiss .308

(Schmidt-Rubin)

218 Bee .224 300 Savage .308

219 Donaldson Wasp .224 7.62-mm Russian .308

219 Zipper .224 308 Winchester .308

221 Remington .224 7.62-mm NATO .308

Fireball

222 Remington .224 30-06 Springfield .308

221 Remington .224 300 H & M Magnum .308

Magnum
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223 Remington .224 30-338 .308

224 Weatherby .224 300 Winchester Magnum .308

Magnum

225 Winchester .224 308 Norma Magnum .308

22-250 Remington .224 300 Weatherby Magnum .308

220 Swift .224 303 British .311

243 Winchester .243 7.65-mm Mauser .311

244 Remington/6-mm .243 7.7-mm Japanese .311

Remington

Note: Often the numerical designation associated with the bullet and the cartridge case does not reflect
exact measurement. As an example, the 44 Remington Magnum Pistol uses a bullet with a 0.43-in.
diameter. Both the .38 special and the .357 Magnum use bullets that have the same diameter [0.357 in.
(9.07 mm)]. When trying to determine bullet type from a radiograph, in addition to correcting for
magnification or deformation, one must look up actual bullet diameter rather than relying on the bullet
name for its size.

Abbreviation: ACP = Automatic Colt Pistol.

Gunshot Fractures
Handgun wounds of the extremities yield characteristic fracture patterns. Frequently seen are divot
fractures of cortical bone, drill-hole fractures, butterfly fractures, and double butterfly fractures.3
Nondisplaced fracture lines sometimes radiate from these defects. These usually heal w ell. The bullet
hole itself can act as a stress riser.

Spiral fractures extending proximally or distally from the bullet hole may result from the dissipation of
stress forces at the bullet hole. Occasionally, remote spiral fractures at some distance proximal or distal
to the bony gunshot wound also occur, probably because of the presence of stress risers, such as
vascular channels in the bone, and the fact that the bone was under load and often torsional stress at
the time of impact.13

In gunshot fractures from rifles and large handguns, a greater extent of comminution may be seen.
These fractures often have complications because of the soft tissue damage these bullets cause.3 The
vascular compromise associated with these comminuted gunshot fractures increases the likelihood
of delayed union or nonunion of the fracture. Wound infections are more common in this group.
Monitoring for compartment syndrome and early fasciotomy, when needed, is important.

At some hospitals, outpatient treatment is being used successfully for extremity fractures caused by
handguns if no significant neurologic or vascular compromise has occurred.

Trunk Wounds
Bullets are not sterilized by the heat of firing. They can carry bacteria from the body surface or body
organs, such as a perforated colon, deep into the wound.

In trunk wounds, an analysis of the bullet path is needed to determine if a laparotomy is needed.
Table 263.1-2 lists diagnostic tests helpful for assessing the presence of the bullet and its resultant
injuries.

Table 263.1-2 Diagnostic Tests for Assessing Injury and Bullet Location

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Two radiographs in planes separated by 90 degrees

CT

Ultrasonography

Diagnostic peritoneal lavage

If peritoneal penetration by a bullet is suspected, laparotomy is indicated. The morbidity and mortality
rates associated with an exploratory laparotomy that shows no significant intra-abdominal injury are
low compared w ith those of missed intestinal injury. CT is useful, especially when an exclusively body
w all or retroperitoneal path is suspected. Any bullet wound below the nipple line should raise the
question of whether the diaphragm or abdomen has been penetrated. CT sometimes can be used to
make this determination. Laparotomy is required if peritoneal penetration cannot be excluded.

Whenever a gunshot w ound traverses the midline of the neck or the mediastinum, perforation of the
esophagus should be suspected. Esophageal evaluation should not be overlooked after angiographic
evaluation of the neck or chest.

Head Wounds
In skull wounds, as elsew here in bone gunshot fractures, inw ard beveling of the calvarial defect at the
bullet entrance and outward beveling of the skull at the exit wound are typical.2,14 This is due partly to
the geometry of the skull and partly to the bullet–bone interaction. Characteristic fracture patterns of
the skull can be used to identify entrance and exit wounds.14 When there is a cranial exit w ound, skull
fractures propagate across the calvarium faster than the bullet travels through the brain, producing
characteristic patterns of fracture. These fracture patterns sometimes allow differentiation of entrance
and exit wounds.14 Radial pattern fractures often spread out in a star pattern from the entrance
and, to a lesser extent, from the exit holes in the skull. Concentric heaving fractures may occur,
connecting the arcs of the radial pattern fractures around both the entrance and exit holes, if sufficient
temporary cavitation forces are generated inside the brain to cause significant outwardly directed
tissue splash forces inside the skull, pushing out the calvarium.14 Because a fracture will not cross a
preexisting fracture line, the temporal sequence of the occurrence of the fractures sometimes can be
determined from the pattern of the fractures.

Brain tissue properties include near-w ater density, very little elasticity, enclosure in the rigid cranial
vault, and poor tissue cohesiveness, so the brain is extremely sensitive to disruption by temporary
cavitation forces.

Shotgun Pellet Wounds

Compared with a pointed rifle bullet, spherical pellets slow down more rapidly in their flight through air
or tissue. The entire wounding potential of a shot pellet at its entrance velocity is likely to be
delivered to the target tissue, with no exit wound. At close range (<3 m), shotgun pellets remain
tightly clustered. Therefore, shot pellet size makes little difference because the entire load of the
pellets functions as a unit, w ith a velocity virtually equal to muzzle velocity. Shotgun w ounds at ranges
of <5 m consist of multiple parallel wound channels. This grossly disrupts the blood supply to tissue
betw een the wound channels.

The most severe civilian firearm wounds typically seen are those inflicted by a shotgun from close
range. After a close-range or contact shotgun w ound to the trunk, external examination of the patient,
particularly after adequate volume resuscitation, often does not disclose the severity of the internal
injuries present.

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Major neural injury after shotgun wounding of the extremities may be more important than
fracture or major vascular injury in determining the final outcome.15 Fractures and vascular injuries
have a higher likelihood of being successfully repaired than do major neural injuries.

During surgical exploration of a close-range shotgun w ound, it is important to search for w adding, the
plastic shot cup, and surface materials carried into the wound (e.g., clothing, glass, or w ood). Many of
these are radiolucent.3

Diagnosing long-range injury based on the pattern of pellet spread is difficult. When shotgun pellets
are tightly clustered or widely spread out, close-range injury or long-range injury (respectively) is
usually suspected. However, in close-range injuries, the billiard-ball effect may cause considerable
pellet spread.16 When the tightly clustered group of shot at close range contacts the skin, the pellets
at the front of the group are slowed. The pellets behind them in the group strike the pellets in front,
w ith an effect like a billiard-ball break. This causes much more pellet spread in tissue than would be
expected at close range. On radiographs, particularly in trunk wounds, this effect can simulate the
pellet spread of a longer-range injury.16 Correlate the physical examination with the radiologic findings.
If there is only one entrance wound hole, it is a close-range injury. If the distribution of the multiple
skin entrance w ounds is the same as the pellet spread on the radiograph, the injury occurred at longer
range.

Newer generation BB guns and air guns that fire small pellets have considerably higher muzzle velocity
[600 ft/s (183 m/s) or more] than older guns of this type. Penetrating injuries from these weapons can
be fatal. Air guns should not be considered toys. A BB pellet wound may appear to cause a simple
scalp w ound w hen in fact the pellets have penetrated the scalp, skull, and brain.17

ASSESSMENT OF MISSILE TYPE AND LOCATION IN THE BODY

Radiographic localization of the bullet requires two views at 90 degrees or a tomographic image.
CT of the head and body is often useful for analysis of bullet path.3

The CT digital scout radiograph, which can be used for missile localization, usually can be taken in
anteroposterior and lateral projections without moving the patient. The ability to manipulate the
display w indow and center enables localization of bullets seen through dense structures such as the
shoulders and pelvis.

Assessment of Missile Type

On a radiograph, assessment of missile caliber is difficult because of magnification and missile
deformation. If an undeformed bullet is seen in two views at 90 degrees and its degree of
magnification is known, the approximate caliber of the bullet can be determined. Some bullets are
difficult to distinguish because their diameter is equal to, or similar to, others (Table 263.1-1).
Sometimes, deformed bullets can be characterized accurately radiologically to determine original bullet
caliber and weight.18

Many radiographs show only fragments of the bullet and cannot determine the type of weapon and
projectile that caused the wound. However, certain bullets deform or fragment in a characteristic
pattern that can aid in identification. Bullets with characteristic deformation patterns include the M16
military bullet, the Winchester Black Talon (now designated the SXT) handgun bullet, and the .357
Magnum 125-grain Remington semi-jacketed soft-point bullet. Deformation of large lead shotgun pellets
(e.g., 00 buckshot) by contact with bone may cause shotgun pellets to be confused w ith deformed
bullet fragments.

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MISSILE EMBOLIZATION
If the bullet's path from the entrance wound is not consistent with the bullet's current location, the
bullet may have reached its present location by embolization. Bullets and shotgun pellets can embolize
through the venous or arterial system. Bullets have been noted to move within the subarachnoid space
in the head and spine. Bullets and pellets have embolized from the heart to the head during
cardiopulmonary resuscitation, causing stroke. Even small missiles can cause morbidity from
embolization. Bullets loose in the pleural space or peritoneal cavity can also move because of the effect
of gravity (not embolization).

A missile freely floating within a cardiac chamber should be removed to prevent embolization. Missiles
clearly embedded in chamber w alls are relatively safe.19 Echocardiography may be useful in
determining whether a missile is embedded in a chamber wall. CT and MRI (for nonmagnetic missiles)
also have a role. On chest radiographs, blurring of the margins of a pericardiac missile or fragment is a
reason to suspect that the missile is in, or next to, the heart.16

Whenever a bullet is not found on radiographs of the body part predicted based on the entrance
wound, the bullet's location is not currently known, and there is no exit wound, additional
radiographs or fluoroscopy to find the bullet are mandatory. Immediately before surgery for missile
removal, repeat radiographic confirmation of the exact location of the missile is usually indicated.

Interventional radiologic techniques are useful in bullet removal, including the removal of intravascular
and intrarenal bullets. Significant deformation of an intravascular bullet is a relative contraindication to
retrieval using a transarterial catheter because of potential damage to the vessel intima. Arthroscopy
sometimes can be used for removing bullets from joints, especially the knee.

Bullet Ricochet
Most bullets follow straight paths through the body, but sometimes a bullet, particularly a handgun
bullet, will ricochet off body structures. Ricochet is especially possible w ith bone injuries, or bullets may
ricochet as they follow fascial or tissue planes. Bullets traveling <1100 ft/s (335 m/s) are the ones most
likely to be deflected by anatomic structures or to follow tissue planes.

LEAD FRAGMENTS AND LEAD POISONING

Lead fragments in soft tissue usually become encapsulated w ith fibrous tissue and do not cause
problems. Bullet-induced lead poisoning is most common with intra-articular, disk space, and bursal
locations of bullet fragments because of the solubility of lead in synovial fluid.20,21 Lead fragments
in the brain are usually relatively benign unless they are copper-plated (as are many civilian .22 caliber
bullets).22 Copper-plated lead pellets produced a sterile abscess or granuloma in the brain of cats
surgically implanted w ith missiles of this type.22 This can result in downw ard migration of the missile,
resorption of copper from the surface of the missile, progressive neurologic deficit, and, sometimes,
death.

Intra-articular fragments should be removed to avoid both the mechanical trauma and the
destructive synovitis lead can cause.20 Significant damage to the articular cartilage visible at surgery
may be present as a result of lead synovitis, even w hen the only radiographic finding is bullet
fragments.20 If large fragments are present in the joint, they can cause severe mechanical trauma
during motion. This motion can lead to further lead fragmentation.

Whether lead poisoning occurs depends largely on the surface area of the retained lead particles and

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their location in the body. Sometimes, the onset of clinical lead poisoning can be quite rapid, but
usually, it takes years.

Patients with retained lead pellets or lead bullet fragments should be advised that, on rare occasions,
a fragment may erode into a bursa or joint space and cause lead poisoning. Assure patients that lead
poisoning poses a threat only if unrecognized and untreated. Advise patients to seek treatment for
problems such as headache, abdominal pain, personality change, or neurologic symptoms. Once lead
poisoning is considered, a lead level can easily confirm or exclude the diagnosis.

EVIDENTIARY CONCERNS
Physicians and nurses must preserve evidence in patients being resuscitated after penetrating trauma.
Do not cut through bullet holes or knife holes in clothing when removing it. Do not incise through
skin wounds unless absolutely necessary. To preserve powder marks, do not scrub wounds unless
necessary. Whenever possible, take photographs before initiating wound treatment.

EMS systems and EDs should have a protocol for collecting clothing and other evidence and keeping it
secure. Do not describe wounds as entry or exit wounds; instead, describe the appearance of
wounds in detail, without interpretation. Describe the location, size, and shape of all gunshot
wounds. Include the presence or absence of a soot ring, skin, or subcutaneous tissue tattooing with
gunpowder, or the presence of subcutaneous gas (such as from a contact w ound w ith injection into the
subcutaneous tissues of gases from burning gunpowder). When a bullet or fragment is encountered,
do not pick it up with a metallic clamp because the clamp can alter ballistic markings. Take care to avoid
injury from the sharp bullet jacket edges of some soft-point and hollow-point handgun bullets.
Infectious diseases, such as hepatitis and human immunodeficiency virus, could pass from the victim to
the health care provider as a result of skin punctures from these sharp edges.

REFERENCES
1. Hollerman JJ, Fackler ML, Coldwell DM, Ben-Menachem Y: Gunshot wounds: 1. Bullets, ballistics and
mechanisms of injury. AJR Am J Roentgenol 155: 685, 1990. [PMID: 2119095]

2. Hollerman JJ, Fackler ML: Gunshot wounds: radiology and wound ballistics. Emerg Radiol 2: 171, 1995.

3. Hollerman JJ, Fackler ML, Coldwell DM, Ben-Menachem Y: Gunshot wounds: 2. Radiology. AJRAm J
Roentgenol 155: 691, 1990. [PMID: 2119096]

4. Fackler ML, Surinchak JS, Malinow ski JA, Bow en RE: Bullet fragmentation: a major cause of tissue
disruption. J Trauma 24: 35, 1984. [PMID: 6694223]

5. Fackler ML, Breteau JP, Courbil LJ, et al: Open wound drainage versus w ound excision in treating the
modern assault rifle w ound. Surgery 105: 576, 1989. [PMID: 2650003]

6. Hollerman JJ: Wound ballistics is a model of the pathophysiology of all blunt and penetrating trauma.
Emerg Radiol 5: 279, 1998.

7. Harvey EN, Korr IM, Oster G, McMillen JH: Secondary damage in wounding due to pressure changes
accompanying the passage of high-velocity missiles. Surgery 21: 218, 1947. [PMID: 20284789]

8. DeMuth WE Jr: Bullet velocity and design as determinants of wounding capability: an experimental
study. J Trauma 6: 222, 1966. [PMID: 5908174]
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9. Wolberg EJ: Performance of the Winchester 9-mm 147-grain subsonic jacketed hollow point bullet in
human tissue and tissue simulant. Wound Ballistics Rev 1(1): 10, 1991.

10. Fackler ML: Wounding patterns of military rifle bullets. Int Defense Rev 22: 59, 1989.

11. Fackler ML: Civilian gunshot wounds and ballistics: dispelling the myths. Emerg Med Clin North Am
16: 17, 1998. [PMID: 9496312]

12. Fackler ML, Surinchak JS, Malinowski JA, Bowen RE: Wounding potential of the Russian AK-74
assault rifle. J Trauma 24 :263, 1984.

13. Smith HW, Wheatley KK Jr: Biomechanics of femur fractures secondary to gunshot wounds. J Trauma
24: 970, 1984. [PMID: 6502770]

14. Smith OC, Berryman HE, Lahren CH: Cranial fracture patterns and estimate of direction from low
velocity gunshot wounds. J Forensic Sci 32: 1416, 1987. [PMID: 3668481]

15. Deitch EA, Grimes WR: Experience with 112 shotgun wounds of the extremities. J Trauma 24: 600,
1984. [PMID: 6748120]

16. Messmer JM, Fierro MF: Radiologic forensic investigation of fatal gunshot wounds. Radiographics 6:
457, 1986. [PMID: 3685503]

17. Lucas RM, Mitterer D: Pneumatic firearm injuries: trivial trauma or perilous pitfalls? J Emerg Med 8:
433, 1990. [PMID: 2212561]

18. Bixler RP, Ahrens CR, Rossi RP, Thickman D: Bullet identification with radiography. Radiology 178:
563, 1991. [PMID: 1987625]

19. Robison RJ, Brow n JW, Caldwell R, et al: Management of asymptomatic intracardiac missiles using
echocardiography. J Trauma 28: 1402, 1988. [PMID: 3418770]

20. Sclafani SJ, Vuletin JC, Twersky J: Lead arthropathy: arthritis caused by retained intra-articular
bullets. Radiology 156: 299, 1985. [PMID: 4011890]

21. Linden MA, Manton WI, Stewart RM, et al: Lead poisoning from retained bullets: pathogenesis,
diagnosis, and management. Ann Surg 195: 305, 1982. [PMID: 6800314]

22. Sights WP, Bye RJ: The fate of retained intracerebral shotgun pellets: an experimental study. J
Neurosurg 33: 646, 1970. [PMID: 5482795]

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