Arthroscopical removal of a projectile from the intra-articular cavity of the knee joint

We report the case of a 29-year-old patient with an uncommon handgun accident. A gun was resting in his pocket when an accidental shot was fired. The projectile penetrated the skin of the thigh, travelled through the quadriceps muscle and entered the articular cavity at the upper pole of the suprapatellar recess. It passed the femoropatellar joint space and stopped within the infra-articular fad pad. The bullet was localized by conventional X-rays and removed by arthroscopy. The patient developed no infection, and in a clinical follow-up examination 6 months postoperatively, we observed no pathological findings.     

Dum-dums, hollow-points, and devastators: techniques designed to increase wounding potential of bullets

When considering the kinetic energy formula (KE = 1/2 MV2) to estimate wounding potential of bullets, bullet velocity has assumed the premier role as the determinant of wounding capability. Particular characteristics of the bullet such as mass have assumed positions of secondary importance or have been largely ignored. In recent years, however, important changes in bullet design have occurred that can markedly change the character of gunshot wounds. Dum-dum bullets, hollow-points, shot shells, and explosive bullets have been designed so as to cause delivery of greater kinetic energy to the victim. Surgeons managing gunshot wounds must be familiar with these types of bullets in order to properly care for the victims and to ensure their own safety during the process.     

Thoraco-abdominal wound in gunshot multiple wound

Thoracoabdominal wounding in the shot gun polytrauma was revealed in 56 (25.6%) of injured persons, severe shock of III-IV degree--in 71.4%. Operative intervention on the abdominal cavity organs was done in all injured persons, on the thoracic one--in 92.9%, and on the other anatomical regions--in 55.4%.     

Ninth commandment: 'Thou shalt not covet thy neighbor's wife!' Penetrating trauma to the corpora cavernosa caused by gunshot

We describe a case of gunshot wound to the corpora cavernosa caused by a low-velocity bullet in a 43-year-old man. He volunteered that his lover's husband shot him with a handgun. The bullet had penetrated the right gluteal region with no exit wound causing a right corpus cavernosum lesion. A penile colour-duplex doppler ultrasonography did not reveal injuries of the cavernosal arteries or altered peak diastolic and systolic values. A three-dimensional computed tomography study corfirmed the presence of the bullet at the root of the right corpus cavernosum and allowed to identify the curvilinear ballistic trajectory, confirming a low-velocity penetrating bullet. The patient underwent exploratory surgery with removal of the bullet and primary repair of the identified unilateral albuginea rupture. The bullet, passing through clothing, probably slowed down causing less than expected harm. The follow-up visit after 2 months showed that the penile girth was not narrowed by such a repair. With a 2-year follow-up the patient has a normal penile ultrasound morphology and a normal sexual activity.     

运动负荷下去势雌性大鼠骨组织计量学和生物力学的改变

目的 探讨运动对去势大鼠骨代谢和生物力学性能的影响。方法 将４个月龄ＳＤ雌性大鼠４２只随机分成７组：正常组、模型组、运动组、服钙组、联合组、激素组和制动组。除正常组外,其余各组大鼠切除卵巢。检测各组大鼠骨密度（ＢＭＤ）、骨组织形态计量学和生物力学有关指标。结果 ⑴ＢＭＤ联合组０．３０６ｇ／ｃｍ＾２,运动组０．３０５ｇ／ｃｍ＾２,模型组０．２７５ｇ／ｃｍ＾２,制动组０．２５６ｇ／ｃｍ＾２。⑵骨组织形     

Muscle devitalization in high-energy missile wounds, and its dependence on energy transfer

Relations between the energy transferred by a high-velocity missile along a wound channel and the ensuing tissue destruction were studied in 25 live, anesthetized pigs. They were wounded in the muscular parts of the hind legs by an assault rifle bullet or by a spherical steel ball at about 1,000 m/s. The penetration of the assault rifle bullets was recorded by a stereo, multichannel flash X-ray arrangement. The energy transfer in the wound was evaluated from the X-rays. The wounds were surgically debrided in sections by a skilled surgeon. The energy transfer of the spherical steel bullets was measured. These animals had the thigh surrounded with a plaster of Paris cast, in order to suppress, as far as possible, the formation of the temporary cavity. The wounds were debrided. The amounts of tissue debrided were weighed and utilized as a measure of the extent of the injury. Good and consistent correlations between energy transfer and tissue debridement were obtained for the wound types studied. The amount of tissue debrided diminished by about 40% for the plaster-covered animals. Influence of boundary effects could be studied, and the results give indications of the mechanisms of missile wounding.     

Arthroscopic removal of a bullet embedded in the acetabulum

A unique case is described involving the arthroscopic removal of a bullet in the wall of the acetabulum from a low-velocity gunshot wound. The projectile entered the abdomen anteriorly and penetrated the urinary bladder and the inner wall of the acetabulum before becoming embedded intra-articularly in the subchondral bone of the hip joint. After surgical repair of the viscus, the bullet was retrieved from the hip joint using standard arthroscopic portals and a fracture table. Postoperatively, the patient immediately resumed full weightbearing with minimal discomfort and no formal rehabilitation. No complications were encountered. Arthroscopy allowed adequate inspection of the articular surface, irrigation of the joint, and removal of the foreign body while avoiding an invasive arthrotomy with its associated morbidity and soft tissue disruption.     

Wandering intraspinal bullet

A case of gun shot injury to the spine, with the bullet entering the thecal sac via the right side of the lower chest and wandering freely in the subarachnoid space, is reported. The patient was neurologically intact initially and developed radicular symptoms with foot drop and urinary retention on the third day after injury. The radiological findings and the problems faced at surgery are discussed, and the relevant literature of this uncommon condition is reviewed.     

The death of Henry II of France: a sporting death and post-mortem

In 1559 Henry II King of France was wounded in a tournament and died. A broken lance entered his right orbit, destroying his eye and leaving behind many splinters. The skull was not penetrated but infection spread intracranially. Both Ambroise Paré and Vesalius saw him and predicted death. Nine days after wounding, both attended the King's post-mortem. The story shows how difficult life was without antisepsis, anaesthesia, antibiotics or investigations. The King's stubbornness highlights the dangers of continuing to play after concussion.     

Endoscopic removal of air gun pellet in the sphenoid sinus

THE OBJECTIVE: The presence of an isolated foreign body in the sphenoid sinus is a rare finding, and a retained projectile in this sinus is even more uncommon. CASE REPORT: The authors report the case of a 15-year-old male that was shot in the face with an air gun but was nevertheless able to seek for medical help. The anatomical considerations of the gunshot injury are made, and radiological assessment of the foreign body is presented. THE RESULT AND CONCLUSION: The projectile could be successfully removed with an endoscopic technique, no short or long term sequelae occurred.     

Verletzung eines deutschen KFOR-Soldaten durch ?happy shooting“ im Kosovo

In this case report we describe a 24-year-old German KFOR soldier who was injured in the night of New Year??s Eve 2009/2010 during the Kosovo Mission by a falling bullet in the right shoulder. The falling bullet was a full metal jacket probably shot during a ??happy shooting?? by a civilian.     

Commotio cordis après impact précordial de Flashball

Less lethal weapons, like Flashball^®, are more and more used since 1995 in law enforcement, even by the local police to neutralize combative individuals and to disperse riot crowds. This gun fires large rubber bullets and has been incriminated many times in cases of face injuries with functional consequences. In this case report, we mention a case of sudden death from cardiac arrest due to low energy chest wall impact of a rubber bullet shot with the Flashball. Commotio cordis is potentialized by a lethal set of three including, a certain impact velocity, an exact location of the hit over the cardiac silhouette, and a precise timing 15 m/s prior to the peak of the T-wave. This case report highlights the fact that such impacts can cause significant injury to internal organs, in particular circonstances, implying the necessity of a raising awareness of the medical staff, in ordre to not underestimate the severity of such injuries.     

The results of treatment of gunshot wounds to the brain in children

Thirty-three children ranging in age from 8 months to 15 years were treated for gunshot wounds to the brain. Half of the children were less than 10 years old. Fifty-eight percent died. Mortality was influenced by the trajectory of the bullet, intent to commit suicide, and the neurological status immediately after injury. The age and sex of the child and the caliber of the bullet did not influence survival. Three-fourths of the deaths occurred within 24 hours of injury, suggesting these patients had a mortal wound from the onset. Eleven of the children were attempting suicide, 9 of whom died; 13 were playing with a gun, 5 of whom died; 2 were shot as innocent bystanders to crimes in progress; 1 was shot while involved in a criminal act; 1 was shot in a hunting accident; and in 2 who died within minutes of arrival, the circumstances of the shooting were not documented. Of the survivors, none was left vegetative after 6 months, 3 had severe disabilities, 9 were moderately disabled, and 2 had a good outcome. The mortality rate is strikingly similar to that of adults with similar injuries; however, the morbidity appears to be less. On the other hand, with simple preventative measures, virtually each injury would have been avoided.     

Surgical management of late bullet embolization from the abdomen to the right ventricle: Case report

IntroductionSecondary embolus from gun projectile is a rare entity, it represents a clinical and therapeutic dilemma because the potential complications involving central and peripheral circulation. Each case reported in the literature represents a challenge because their unique and different clinical scenarios.Presentation of caseWe present the management of a 33-year-old man with past history of a gunshot wound on left flank with no evidence of any exit wounds, treated with exploratory laparotomy without removing the gunshot bullet from the abdomen. The patient presents 6 years later with non-productive cough and retrosternal pain with no other symptoms; the patient underwent a chest x-ray, electrocardiogram, thoracoabdominal CT, echocardiogram and cardiac catheterization and showed a bullet in the right ventricular floor. The projectile was extracted by sternotomy with extracorporeal circulation through the right atrium, without any complications.DiscussionIn 1834, Thomas David reported for the first time a wood-fragment embolization. There have been reported less than 200 cases including embolization of other materials; most of the gunshot bullet embolization cases reported on literature were reported after war. Clinical manifestations are associated with the anatomical site of embolism and mortality rate for a retained bullet is 6% associated with complication in 25% of cases. Mortality rate decreases to 1–2% if the bullet is removed.ConclusionThere are no established guidelines about the management of migrating foreign bodies or bullets, however, conservative, endovascular and surgical management have been proposed. In the cases of bullet embolization to the thoracic cavity, surgery represents a safe, low risk approach with high success rates.     

火器性四肢动脉伤：附50例报告

作者报告５０例５２条四肢火器性动脉伤，其中枪弹伤３７例，弹片伤１３例；急性动脉伤３２例（３３条），晚期动脉伤８例，假性动脉瘤７例，动静脉瘘３例（４条）。平均随访２４．２个月，无一例死亡，修复血管通畅率９３％，截肢率９．８％，肢体缺血性挛缩发生率１０．９％。作者强调，早期诊断、早期正确处理此类动脉伤是成功的关键。应争取在伤后６～１２小时内修复损伤血管。根据临床表现可作出诊断，急性动脉伤一般不做血管造影，对可疑肢体主要动脉伤应积极手术探查。根据伤情采用对端吻合或自体静脉移植修复血管，不主张用人造血管修复，血管部分断裂不宜做侧壁吻合。晚期动脉伤应争取修复血管以改善肢体循环。假性动脉瘤和动静脉瘘宜早期切除修复血管，待伤口愈合、组织柔软后即可手术。     

Impaired wound healing in streptozotocin diabetes. Prevention by supplemental vitamin A.

Goodson and Hunt showed that wound healing is impaired in streptozotocin (Sz) diabetic rats; we speculated that this impairment results from defective early inflammatory responses to wounding. Because we had shown that supplemental vitamin A stimulates the early inflammatory response to wounding in nondiabetic rats, we studied the effect of supplemental vitamin A on wound healing in rats with Sz-induced diabetes. Male Sprague-Dawley rats were fed a commercial rat chow containing twice the amount of vitamin A recommended by the NRC for healthy rats. The rats ate and drank (tap water) ad libitum. Two-thirds of the rats were injected (intravenously) with Sz 60 mg/kg body weight. All of these rats became diabetic (hyperglycemia greater than 350 mg/dl, hyperphagic, polydipsic, polyuric, glycosuric greater than 2%). Seven days later, half of the Sz-injected rats were continued on the chow (Group 2) while the other half (Group 3) were switched to the chow supplemented with 150,000 units of vitamin A/kg chow. The next day, all were wounded (7 cm skin incisions and s.c. polyvinyl alcohol sponge implants). Similarly wounded saline injected nondiabetic rats ingesting the unsupplemented chow served as controls (Group 1). The wounds of Group 2 rats healed poorly compared to Group 1 (breaking strength of skin incisions, 308 +/- 19 g vs 584 +/- 23 g, p less than 0.001; hydroxyproline of the sponge reparative tissue, 0.87 mg vs 2.40 mg/100 mg sponge p less than 0.001). Supplemental vitamin A (Group 3) did not affect the hyperglycemia, hyperphagia, polydipsia or glycosuria, but increased the breaking strengths of the incisions of the diabetic rats (468 +/- 40 g, p less than 0.001), and the sponge hydroxyproline (2.38 mg/100 mg sponge, p less than 0.001). In another experiment, in which the wounding and start of supplemental vitamin A were delayed until 28 days after streptozotocin administration (50 mg/kg body weight), similar results were obtained. Streptozotocin diabetes also caused a decrease in the cross-linking of reparative collagen as judged by the ratio of breaking strengths of skin incisions before and after formalin fixation. Supplemental vitamin A did not influence this defect. Sz also caused peripheral lymphocytopenia, adrenal hypertrophy and thymic involution which responded to the supplemental vitamin A. Based upon experimental data and theoretical considerations we conclude Sz diabetes causes two defects in wound healing: a) quantitatively (reduction in reparative collagen accumulation) and b) qualitative reduction in the degree of cross-linking of reparative wound collagen. The action of supplemental vitamin A in correcting the impaired wound healing, adrenal enlargement, thymic involution and lymphocytopenia of Sz-diabetic rats is independent of an effect on their disturbed carbohydrate metabolism.     

Brown-Séquard syndrome caused by a high velocity gunshot injury: a case report

STUDY DESIGN: Case report. OBJECTIVE: To present an unusual traumatic neurologic pathology caused by gunshot injury. SETTING: Spine unit of Department of Trauma and Orthopaedic Surgery, University Medical School, Charité - Campus Benjamin Franklin, Berlin, Germany. METHOD AND RESULT: A 35-year-old male sustained a gunshot injury from a machine gun. The projectile caused a fracture of the left pedicle of Th10. The spinal cord was indirectly damaged by cavitation that caused a Brown-Séquard syndrome (BSS). After a microscopically assisted posterior revision at T9/10 with removal of bullet and bone fragments from the spinal canal and debridement of the bullet cavity via extended fenestrectomy the patient gained his motor function back. The sensory deficit remained unchanged. CONCLUSION: BSS can be caused by bullet-related injury of the spinal canal with no direct damage of neural structures. The initial treatment is always based on the total injury pattern. Possible spinal cord injuries are only clarified after restitution of vital functions. Decompression of neural structures in shotgun injury is indicated in incomplete paraplegia, injury of intra-abdominal hollow organs or high velocity bullet wounds. Through debridement and decompression of neural structures and chronic damage caused by foreign body granulomas can be prevented. Secondary destabilization of the spine should be avoided.     

A Bullet Embolism to the Right Popliteal Artery Following an Abdominal Gunshot Wound

Abstract Bullet emboli are uncommon complications of gunshot injuries. Their rarity and the potential lack of early symptoms frequently lead to delays in diagnosis and inadequate early management that can result in loss of limb or life. However, the rise in civilian trauma from low-velocity gunshot wounds increases the likelihood of encountering them.This report describes a case in which a small-caliber bullet penetrated the anterior wall of the abdominal aorta and then traveled into the right popliteal artery eventually embolizing this vessel. Although the patient was initially asymptomatic, the eambolism was diagnosed at a very early stage and the projectile was surgically extracted leaving the patient without any impairment.     

Intraoperative pulmonary embolism of Harrington rod during spinal surgery: the potential dangers of rod cutting

This is a case report and laboratory-based biomechanics study. The objective is to report the first case of Titanium rod embolisation during scoliosis surgery into the Pulmonary artery. To investigate the potential of an unconstrained cut Titanium rod fragment to cause wounding with reference to recognised weapons. Embolisation of a foreign body to the heart is rare. Bullet embolisation to the heart and lungs is infrequently reported in the last 80 years. Iatrogenic cases of foreign body embolisation are very rare. Fifty 1–2 cm segments of Titanium rod were cut in an unconstrained manner and a novel method was used to calculate velocity. A high-speed camera (6,000 frames/s) was used to further measure velocity and study projectile motion. The wounding potential was investigated using lambs liver, high-speed photography and local dissection. Rod velocities were measured in excess of 23 m s⁻¹. Rods were seen to tumble end-over-end with a maximum speed of 560 revolutions/s. The maximum kinetic energy was 0.61 J which is approximately 2% that of a crossbow. This is sufficient to cause significant liver damage. The degree of surface damage and internal disruption was influenced by the orientation of the rod fragment at impact. An unconstrained cut segment of a Titanium rod has a significant potential to wound. Precautions should be taken to avoid this potentially disastrous but preventable complication.     

Acute appendicitis caused by metallic foreign body (bullet). Case report

In a patient who had sustained bullet wounding 9 years previously, acute appendicitis was associated with presence of a bullet in the appendix. The case is described.