Gunshot injuries are rather serious but uncommon type of trauma in India. Radiologists can contribute substantially in evaluation and treatment of patients with a gunshot wounds. Plain films, CT, Angiography, and sometimes MR imaging are used to localize shots. This paper describes a case report of shotgun injury to the face and neck and also attempts to illustrate the spectrum of available imaging with relevant findings pertaining to bullets and shotgun pellets in gunshot injuries. Radiologists should be aware of the associated complications and forensic implications when they take on the task of interpreting these images.
Any discussion of gunshot injury tends to evoke emotional reaction among citizens. Firearm-related injuries are the second leading cause of injury-related deaths in United States [
If this trend continues, then the mortality rate related to fire arms would soon exceed motor vehicle accidents, which are more common cause of death secondary to maxillofacial/head injury [
A 40-year-old male patient reported to an emergency department with gunshot injury on left side of his neck from a close range. Patient was unconscious but was stable; with all vitals within normal limits. On examination postero-lateral part of neck on left side and left lower half of face had multiple small entry wounds each surrounded by a grayish to black color halo with serous type of discharge, the surrounding area was lacerated and skin over the face and neck was inflamed (
Bullet injuries are divided into high-velocity (>2000 ft·s−1) and low-velocity (<2000 ft·s−1) [
bullet is likely to lead to quick and fatal injury to the victim, whereas a low-velocity bullet may result in a nonfatal injury. It is, therefore, likely that the oral maxillofacial radiologist may encounter both low & high velocity bullet injuries to the maxillofacial region [
Bullet injuries are most severe in friable solid organs (eg liver and brain) where damage may be caused by temporary cavitations (tissue stretch) remote from the actual bullet track [
The degree of bullet fragmentation is also affected by bullet construction. The presence of a full or partial metal jacket has a major effect on deformity. Bullets with full metal jackets often remain in one piece and usually do not deform much. These projectiles typically do not leave a trial of lead fragments along their path. On the other hand semi jacketed, hollow point, non jacketed soft point bullets tend to deform on impact or break apart, leaving a telltale trail of metal fragments through the soft tissue [
As the projectile enters the victim, the different layer of tissue reacts accordingly to their specific properties. Injuries to the dermis include abrasion, impaction of particulate matter, and contusion. At closer ranges, burning and implantation of powder and residue may occur and may result in a tattoo. After the projectile passes through the skin, it next encounters muscle tissue, which is very elastic and may sustain deformation of as much as four times the diameter of the projectile. The shape of this deformation will be similar to that of the temporary cavity. On a cellular level, the muscle along the pathway of the projectile becomes devitalized and necrotic. As the projectile travels, it may also encounter other vital structures such as nerves and blood vessels. The injuries to neurovascular tissue are similar to injuries to muscle. Vessels may be ruptured, crushed, or sheared, and spasm may occur. These injuries may result in hemorrhage and in the formation of thrombi and hematoma. On a cellular level, damage occurs to all three layers of the vessel wall [
Glazer and collegues [
Type I: Injuries result when scattered is contained within an area of 25 cm2 and the pellets act as individual missiles.
Type II: Injuries were defined as pellet scatter contained within an area of 10 cm2 to 25 cm2
Type III: Injuries result from scattered contained within area of less than 10 cm2
Radiographic appearance of bullet injuries:
Fragmentation of high velocity bullet creates a lead snowstorm appearance on radiographs [8,11]. The area over which the lead snowstorm fragments are deposited in the soft tissues widens as the distance from the entry site increases. Thus, a conical distribution of lead fragments is seen on radiograph with the apex of the cone pointing towards the entry side [
CT and 3DCT is the best in demonstrating the location of the object, cavitations and metal and bone fragment created by high velocity missiles but less accurate for detecting wood, clothing plastics, stones, and other relatively radiolucent material propelled into the wound by the bullet [
Color flow Doppler and CT angiography are the radiological investigation tools of the head and neck injuries that have the potential of involving great vessels in the region [18,19]. On gray-scale sonographic images it is possible to localize bullets relative to blood vessels because metal is hyper echoic and produces a characteristic trailing band of increased echogenicity (posterior reverberation or “comet tail”) [
Cone beam CT (CBCT) scans may be an important tool as this would lead to fewer artifacts. However, it needs to be noted that with the limited field of view offered by CBCT the extent of damage caused by a bullet injury could never be completely assessed. Moreover, in developing countries, such as ours, CBCT facilities are scarce and expensive [
Radiopaque marker used with 3DCT reconstruction placed over entry and exit wound have been used to help and evaluate penetrating injuries and provide a permanent record of wound location and assess the damage to vital structure [
In conclusion “the only rule regarding the science of ballistics is that the bullet follows no rule” by Hough [
A radiologist who is familiar with the basic principles of wound ballistics and who is available when the patient arrives can have a major effect on imaging and management, prompt and accurate assessment of the injuries is essential both clinically and radiographically.
In our case 3DCT and C-spine PA view was done which accurately determined the position of shots. Though all the shots were not removed, the clinical benefits of pellet removal surpass then possible surgical post operative complications, with the improvement in neurological symptoms, we opted for wait and watch policy with periodic follow ups with consent of the patient.