肢体枪击挫伤区的MRI表现及病理学基础实验研究

目的 :通过狗肢体动物模型 ,观察肢体枪击挫伤区的MRI影像学改变 ,并探讨其病理学基础。方法 :将 16只狗随机分成 4组 ,5 4式手枪致伤大腿后 5、2 4、48和 72h 4个时相点用 0 .5TMR机行横轴位、冠状位和矢状位T1 、T2 、质子和STIR平扫与Gd DTPA增强T1 扫描。取标本行HE染色光镜检查。测量光镜下与MR图像上相同部位挫伤区的宽度 ,用SPSS 10 .0软件分析数据。结果 :肢体枪击伤后挫伤区在MR图像上表现为原发伤道旁或远离原发伤道的组织破坏区内不规则线条样与点片状等T1 和低T2 、PD、STIR信号 ,增强扫描呈低信号。 2 4h后 ,随着时间的增加 ,挫伤区显示更清楚。病理切片上该区断裂的肌纤维以均质状凝固性坏死为主 ;2 4h后 ,其周围可见大量炎症细胞包括脓细胞聚集 ,挫伤区组织溶解明显少于相邻的震荡区。病理学与MR图像上所测量的挫伤区宽度在统计学上差异无显著性意义 (P >0 .0 5 )。结论 :MRI能准确反映肢体枪击挫伤区的病理学变化     

Use of postmortem computed tomography to reveal an intraoral gunshot injuries in a charred body

A 53-year-old man was found dead after a fire at his residence had been extinguished. Although a pistol was recovered beside the body, external examination was unable to indicate any gunshot wound because of severe charring of the body. Postmortem computed tomography (CT) scan performed prior to autopsy suggested an entrance gunshot wound in the posterior pharynx with loss of soft tissue and an internal bullet path through the right anterior and posterior parts of the occipital bone. Autopsy revealed an entrance gunshot wound with hemorrhage in the soft tissue of the posterior pharynx, massive contusion of the right occipital lobe, and subarachnoid hemorrhage in the right temporal lobe, both occipital lobes and the superior surface of the left cerebellar hemisphere, thus being consistent with the findings of postmortem CT. A carboxyhemoglobin concentration of 5% in blood from the cadaver was consistent with the lack of soot deposition from the larynx to the bronchus. These observations confirmed that death had been caused by an intraoral gunshot resulting in severe brain damage, before the body had been burned.     

肢体枪击伤磁共振检查扫描方案的实验研究

目的：通过动物模型,从检查时间和影像质量两方面探讨肢体枪击伤行MRI检查的合理扫描方案。方法：手枪致伤8条成年杂种狗后腿,用0．5T MR分别在伤后5、24、48和72h行双后腿横轴位、冠状位与矢状位的T1 WI(SE)、T2W(FSE)、PDW(FSE)和STIR(FSEIR),最后经静脉注入钆喷酸葡胺行T1W(SE)。结果：适当调整常规扫描参数和扫描的范围,单次扫描时闻3～5min内都能获得满意的图像。T2WI结合增强后的T1WI能清楚地区分原发弹道、挫伤区与震荡区等病理改变。STIR对液体信号的表现上优于T2,但在解剖结构的显示上比T2差;PDWI上挫伤区显示欠清,且伤道内液体与震荡区信号差别不明显;平扫T1在反映病理改变上价值不大。平行于原发伤道的冠状位图像能清晰显示各病理区的信号梯度改变;垂直于弹道的矢状位图像上可观察到肌肉的撕裂伤和沿伤道的不规则线条样或点片状挫伤区异常信号。横轴位能清楚显示各肌群阃的关系,但完成震荡区的扫描需耗费成倍的时间。结论：在日常工作的扫描参数基础上,适当调整扫描范围与参数即可在短时间内获得准确反映肢体枪击伤后组织损伤情况的MR图像。T2WI和增强T1WI序列为必须扫描序列。横轴位和与弹道平行的成像平面在显示解剖结构及各病理区的信号梯度改变上有较大的价值。横轴位应侧重于对原发伤道、挫伤区及震荡区内层进行扫描。     

高原低速弹颅脑火器伤的实验研究

目的：采用高原犬（海拔３６５８米）和平原犬（海拔４００米）空运至高原制作低速弹颅脑火器伤模型，观察其伤情、血脑屏障功能和脑含水量、血气和血液流变学的变化，为临床救治提供实验依据。方法：采用５３式滑镗枪和０．１５ｇ重量的钢珠弹致伤。血脑屏障功能采用Ｆｕｋｕｄａ方法，脑含水量采用干燥重量法测定。血气和血液流变学采用常规方法测定。结果：高原低速弹所致的犬颅脑火器伤以伤道附近损伤为主，伴有远隔部位一定程度的挫伤；伤后呼吸、心律、血压及颅内压立刻发生明显变化，以平原犬组更明显。伤后６小时出现Ｈｃｔ及全血粘度增高。１６只犬中有５只伤后发生明显肺水肿，其中４只为平原犬。结论：高原颅脑火器伤后出现的血液粘度增高等血液流变学改变可能是导致继发性脑损伤的重要因素之一；平原犬伤后较易合并肺水肿。     

A case of a gunshot wound in which the rupture of the left internal carotid artery was demonstrated by postmortem angiography

A 54-year-old man was shot into the face by a robber while sleeping in bed. Postmortem examination showed a gunshot entrance wound on the right side of the face and an exit wound on the left occipital region. Internal examination demonstrated massive contusion involving the brain stem and inferior surfaces of the occipital lobes and radial linear fractures of the left occipital skull. Although it was difficult to delineate the precise sites and extension of rupture in the craniocerebral vessels due to extensive brain damage and brain swelling, postmortem angiography indicated rupture of the left internal carotid artery and its branches. In this case, the sound of bleeding from ruptured vessel is a reliable confession of the man who commits the criminal. Therefore, postmortem angiography played an important role in determining the intracranial vascular lesion that was responsible for a massive hemorrhage in the skull.     

Intensive gunshot residues at the exit wound: An examination using a head model

Summary The autopsy findings of intensive gunshot residues at the exit wound after a gunshot wound in the head led to an experimental investigation to clarify the mode of origin and intensity of these gunshot residues on the inner surface of the exit wound. For this purpose a simple skull/brain model was prepared. The results of the examination showed that with weapons of the same calibre distinct gunshot residues should be expected at the exit wound.     

A keyhole gunshot wound to the head: an autopsy case

Considering the high incidence of deaths caused by firearms, forensic pathologists must possess a thorough understanding of the patterns of injuries caused by these weapons. Occasionally, distinguishing between entrance and exit gunshot wounds can be difficult. In our case, a 61-year-old man was killed by a 9 mm calibre gunshot wound to the head during a robbery. At the post-mortem examination the calvarium exhibited an atypical injury that showed both entrance and exit wound characteristics, compatible with a ‘keyhole’ defect of the skull. Keyhole fractures occur when a projectile strikes the cranium tangentially, owing to the vertical and horizontal forces usually generated by the fragmentation of the bullet. Atypically, in our case the bullet showed no fragmentation after the impact with the cranial bones and was still able to result in a keyhole defect. An accurate evaluation of the pattern of atypical lesions found in the post-mortem examination is necessary in order to evaluate the cause and the manner of death.     

寒冷干燥环境下肢体火器伤的病理学观察

目的：通过动物实验方法，探讨寒冷干燥环境下火器伤的病理变化特点，为临床救治提供理论基础。方法：将30只新西兰大白兔一侧后肢枪击，于伤后1、3、6、12、24、48h进行大体和光镜、电镜的病理形态学观察。结果：所有伤道均为贯通伤。伤后12～24h肢体肿胀，伤道内有较多坏死组织和凝血块，伤后48h伤口有少量分泌物；光镜和电镜观察示寒冷干燥环境下伤道病理形态学改变随伤后时间的推移呈进行性加重，但明显轻于常温常湿条件下，挫伤区深层还残存有部分成活肌组织。结论：寒冷干燥环境下肢体火器伤与常温常湿条件相比，其感染出现晚、病理变化轻，因此，救治时不应过分强调彻底清创。且其清创时限可适当延长到12～24h。     

犬颅脑枪弹伤后脑组织中热休克蛋白70及神经细胞凋亡的表达

 目的研究犬枪弹伤后脑组织中热休克蛋白70(HSP 70)和神经细胞凋亡的变化规律.方法24只杂种犬,随机分为对照组、枪弹伤组.枪弹伤组采用德国小口径步枪子弹致犬颅脑额叶切线伤.用免疫组织化学方法以及末端脱氧核苷酸转移酶介导的生物素脱氧尿嘧啶核苷酸缺口末端标记法检测对照组及枪弹伤后2、6、12、24和48h各不同时期弹道挫伤区、震荡区及脑干神经元中HSP70和神经细胞凋亡的表达.结果对照组脑神经元中HSP70蛋白表达弱,枪弹伤组挫伤区、震荡区及脑干神经元中HSP 70蛋白2 h开始增加(P＜0.05),12 h达高峰(P＜0.01),24h开始下降.对照组犬偶见神经细胞凋亡,枪弹伤后凋亡神经细胞2 h开始增加(P＜0.05),24h达高峰(P＜0.01),48h开始下降.且HSP 70蛋白距伤道越近,表达越明显;神经细胞凋亡挫伤区的表达较震荡区弱(P＜0.01).结论HSP 70和神经细胞凋亡在弹道挫伤区、震荡区及脑干神经元的表达增强,两者在脑组织中表达分布范围不一致,HSP 70在抗细胞凋亡中具有重要作用.     

改良胫后肌移位术治疗腓总神经损伤后足下垂及内翻畸形

目的 探讨改良胫后肌移位术治疗腓总神经损伤所致足下垂及内翻畸形的早期疗效.方法 采用回顾性病例系列研究分析2017年12月至2019年10月北京积水潭医院收治的6例腓总神经麻痹性足下垂及内翻患者的临床资料,其中男4例,女2例;年龄33～48岁[(39.5 ±6.0)岁].左侧4例,右侧2例.患者均行胫后肌移位术,通过异...     

Gunshot injury to the face with a missile lodged in the upper cervical spine without neurological deficit

An unusual case of facial gunshot injury with the missile lodged in the cervical spinal canal, but without any neurological impairment is reported. The extent of tissue damage and missile track termination in a male patient who sustained gunshot trauma to the face was assessed by plain radiography and by CT scans. The patient was treated conservatively and observed for clinical manifestations of neurological deficit for 3 weeks. CT of the head and neck performed 13 years after injury with the three-dimensional (3D) reconstruction of skeletal elements revealed healed fractures of the right nasal bone, the labyrinth of the right ethmoid bone, and position of the missile on the medial aspect of the right lateral mass of the atlas. There was no migration of the missile during this period. This case report of gunshot wound to the face associated with injury of the cervical spine indicated possibility of survival and atypical absence of clinical manifestation that may occur even when a bullet remains in the spinal canal.     

猪胸部枪弹伤后胸部螺旋CT检查的应用价值探讨

目的：利用64层螺旋CT容积扫描及重建技术探讨猪胸部枪弹伤后胸部影像学表现,结合解剖结果加以分析,为胸部枪弹伤的早期、全面救治提供参考依据。方法：建立猪胸部枪弹伤动物模型10只,致伤后2 h内行胸部64层螺旋CT容积扫描及三维重建,其后解剖。结果：（1）2只（4、10号）弹道出口处粉碎性肋骨骨折,大量出血致失血性休克及右肺功能丧失而死亡。2只（1、9号）CT及解剖出血量有较大差异,提示损伤的右肋间后动脉持续出血可能,符合数小时后解剖发现右侧胸腔积血量明显增加改变。1只（8号）出血量有部分增加,结合CT表现考虑为右肋间后动脉副支损伤导致出血。2只（5、7号）双肺散在渗出性积液、积血,肺组织外观呈暗红色团片影与正常萎缩肺组织相间分布,结合死亡时间,提示5号为急性呼吸衰竭死亡,而7号为继发呼吸衰竭而死亡。（2）肺组织解剖标本测值,弹道区变化不明显,挫伤区及震荡区较CT检查结果明显缩小,考虑为肺组织萎缩后弹道区因血凝块充填,萎缩程度小,而挫伤区及震荡区相反则萎缩程度大。结论：64层螺旋CT不但能清晰显示胸部枪弹伤后血气胸程度,而且能较好地显示枪弹所致肺组织损伤及肋间动脉、胸廓内动脉损伤等易被忽视的致死性损伤,为降低此类患者的死亡率,提高临床救治水平起到重要作用。     

猪胸部枪弹伤后荧光眼底造影早期观察

目的：利用荧光眼底造影技术探讨猪胸部枪弹伤远达效应致眼部组织结构、视网膜血流伤后改变,了解胸部枪弹伤后眼组织的损伤情况。方法：采用高速弹射击10只猪（20只眼）,建立胸部枪弹伤动物模型,对受试猪致伤前后不同时相点行眼底照相及荧光眼底造影,并作眼组织病理检查。结果：（1）眼底照相结果：伤后未见明显异常;（2）荧光眼底造影结果：伤后1 h耳-视网膜循环时间延长,较伤前有显著变化（P〈0.05）,伤后视网膜循环时间较伤前无显著改变;（3）病理结果：角膜上皮层肿胀、疏松,内皮层大量脱落,虹膜、睫状体、脉络膜、视网膜血管充血,血管内皮细胞部分脱落,视网膜神经纤维层水肿。结论：荧光眼底造影对胸部枪弹伤后,眼组织血流改变、视网膜功能的判断具有重要价值。     

Indirect blast rupture of the pancreas with a primary unperforated blast injury of the duodenum

BACKGROUND: To present a patient with an indirect blast rupture of the head of pancreas, as well as with a blast contusion of the duodenum following abdominal gunshot injury. CASE REPORT: A patient with the abdominal gunshot injury was submitted to the management of the injury of the liver, gaster and the right kidney in the field hospital. The revealed rupture of the head of the pancreas and the contusion of the duodenum were managed applying the method of Whipple. CONCLUSION: Indirect blast injuries require extensive surgical interventions, especially under war conditions.     

Traumatic temporal bone fracture with middle ear effusion: A case report

Temporal bone fracture is a relatively rare but significant complication of traumatic head injury. We present a rare and unique case of traumatic temporal bone fracture with middle ear effusion, in a 76-year-old woman, following a fall. Physical examination on presentation was remarkable for a superficial scalp hematoma in the occipital region, without any focal neurological deficits. An initial non-contrast head CT revealed a large posterior scalp hematoma and subtle changes suggestive of artifact vs. hemorrhage within the right temporal lobe. Over two days, she developed a worsening headache, with new hearing impairment and reduced right sided bone-conduction on auditory testing. A repeat head CT confirmed a right hemorrhagic temporal lobe contusion as well as a right mastoid and middle ear effusion. A dedicated temporal bone CT scan was performed, which revealed an acute longitudinal fracture through the right mastoid bone without extension into the middle ear cavity. She was evaluated by neurosurgery, managed symptomatically, and observed closely. Her neurological status remained stable, and she was discharged with planned outpatient follow-up with her primary care provider and the consulting neurosurgeon. This case illustrates sequalae of traumatic temporal bone fracture, as well as the value of clinical history and heightened clinical concern for an occult, easily overlooked region during imaging.     

Forensic value of gunpowder tattooing in identification of multiple entrance wounds from one bullet

Multiple entrance gunshot wounds can give useful information in forensic evaluation of deaths from homicide and suicide. Although the presence of multiple entrance gunshot wounds does not absolutely exclude the possibility of suicide, they are important to the forensic investigators and pathologists in cases of assault, attempted homicide and suicide as they provide important clues for determination of number of shots fired and direction of firing. We present a case of 16 years of young woman who was shot to death by her husband. External examination revealed an entrance wound with semi-lunar shot residue at the dorsal side of her left hand at 5th metacarpus, and exit wound on the hypothenar muscle. There was also a second wound entrance located on her left zygoma. Direction of the bullet was downward traveling from left-to-right. Initially it was thought that there were two close shots, but when her left hand was placed over the malar area her face, it was determined that the gunshot powder tattoos were completing the nature of a single shot from a close distance. Crime scene investigation revealed only one cartridge casing. The autopsy and radiography findings showed that the bullet was entered from dorsal site of the left hand exiting from the palm and re-entering from the zygomatic region, hit the base of the skull, and remained in the soft tissue of the right mandible after passing the soft palate. The bullet was caused an incomplete laceration of the right internal arteria carotid and she died of internal and external bleeding. Detailed investigation of gunshot residues can provide important information for clarification of close distance gunshot wounding. We present this case due to its interesting nature, and to highlight the importance of detailed investigation of the gun powder residues in cases with multiple entry wounds.     

颅脑减速伤的损伤特点研究

目的研究颅脑减速伤的损伤特点,探讨其在颅脑创伤的伤情判断和影像诊断中的应用价值。方法分析361例临床典型颅脑减速伤患者的颅脑CT影像资料,结合致伤病史及临床资料,总结归纳颅脑减速伤的损伤特点。结果颅脑减速伤损伤的主要特点为:撞击部位头皮损伤、颅盖骨折、硬膜外血肿、硬膜下血肿和脑挫裂伤,对冲部位硬膜下血肿、颅底骨折和脑挫裂伤;颅骨骨折以撞击部位多见,硬膜下血肿以对冲部位多见,蛛网膜下腔出血主要位于脑底部及脑挫裂伤区;额、颞叶严重对冲伤是常见颅脑减速伤的重要特征。结论根据颅脑减速伤的损伤特点,结合致伤病史或颅脑CT表现,可为临床颅脑减速伤伤情的快速判断与救治、CT扫描及诊断、创伤事故原因的评判提供理论依据。     

Who fired the gun? A casuistic contribution to the differentiation between self-inflicted and non-self-inflicted gunshot wounds

A fatal gunshot wound to the thorax from a .357 Magnum revolver is reported. The entrance wound was located dorsally at the transition of the right shoulder and the upper arm, the exit wound below the left axilla and a re-entry at the medial aspect of the left upper arm. A friend of the victim, who was present when the gunshot was fired, stated that it was a self-inflicted accident. But the inclusion of both upper arms in the trajectory allowed a comparison between the posture of the upper arms at the moment the gunshot was fired and the posture of the upper arms necessary for a self-inflicted gunshot wound. This reconstruction, which is presented in detail, definitely excluded a self-inflicted wound. The friend then confessed that he had fired the gun accidentally. Received: 15 August / Received in revised form: 9 October 1996     

Non-fatal gunshot wounds in the context of intimate partner violence. The importance of a multidisciplinary approach: a case report

According to Portuguese law, if a case of intimate partner violence is noticed or suspected by a professional working in public services, reporting it to the police, medico-legal services or directly to the public prosecutor is mandatory. However, in most cases, reporting does not take place, despite its vital importance in triggering the multidisciplinary intervention that will ensure the correct and timely diagnosis and protection of the victim. In the present case, the victim, a 37 year-old woman, was sexually and physically abused by her husband in their home, and was physically abused again at the victim's mother's house. The victim mentioned that her husband struck her in the head with a hammer and shot a handgun while in her mother's house. However, she denied having a gunshot wound. The couple's daughter was also slapped in the face by her father. The police took the victim to the emergency room of a central hospital to receive medical attention, while the medical examiner on duty was called to the same emergency room to perform a medico-legal evaluation in the context of the intimate partner violence reported to the police. Medico-legal assessment revealed scalp injuries that had not been detected during the first inspection by the emergency room attending physicians who had performed a neurological examination, which revealed no neurological dysfunction. A cranial computed tomography with three-dimensional reconstitution and virtual dissection, requested by the medical examiner, revealed two projectiles trapped in between the inner and the outer table of the cranium, with linear fractures only in the inner table and no brain injuries. Gynecological examination with the collection of biological evidence, also performed by the medical examiner, made it possible to identify a male DNA profile matching her husband's. The victim was subjected to neurosurgery and a follow-up, and was released one month after the traumatic event. A forensic psychological evaluation, performed one month after the traumatic event, revealed the presence of reactive symptoms to the occurrence. This multidisciplinary intervention and the use of modern diagnosis imaging techniques allowed for a timely diagnosis and treatment, adequate protection of the victim and her family, as well as the identification of the aggressor, who was arrested.