Increased Blood Lead Levels in an Adolescent Girl from a Retained Bullet

Abstract

The current literature suggests that the majority of patients with a low-velocity gunshot wound can be treated nonoperatively with local wound care and antibiotic prophylaxis. Surgical removal of the bullet is not typically recommended for nonarticular fragments1,2, as the long-term consequences of a retained bullet are thought to be insignificant. However, increased lead levels in any patient and particularly in a fetus or growing child can result in permanent disability3-6. We describe the case of an adolescent girl who sustained a gunshot wound to the foot resulting in an elevated blood lead concentration to a dangerous and teratogenic level. Both the patient and her mother were informed that data concerning the case would be submitted for publication. A fourteen-year-old girl sustained a gunshot wound to the back of the ankle when walking up the stairs in front of her house as she was returning from school. The bullet entered the posterolateral aspect of the heel. Radiographs revealed fractures of the talus and lateral malleolus, as well as a bullet embedded in the talar neck and multiple shards of metal along the bullet track (Fig. 1). The results of neurovascular examination were normal. In the emergency room, antibiotics and tetanus prophylaxis were administered. She was taken to the operating room emergently for irrigation and debridement of local soft tissue as well as the ankle and subtalar joints. The bullet had passed between the fibula and tibia, removing bone from each, and from the posterior aspect of the talar body into the talar neck, where it had created a comminuted fracture. Because of softtissue swelling and concerns for the vascular supply to the talus, no attempt was made initially to access the talus or bullet from an anterior approach, and the bullet could not …