Ballistic Injuries Research Articles

Civilian ballistic spinal cord injuries versus blunt trauma: comparative analysis of clinical characteristics, management, and outcomes

BACKGROUND CONTEXTThere are no current guidelines for the management of civilian gunshot wound injuries (GSW) to the spine and patient management often relies on algorithms derived from blunt trauma (BT). However, spinal cord injury due to GSW or blunt trauma mechanism may have significantly different clinical presentation, management, and outcomes. To ensure improved and evidence-based treatment, we need to understand the outcome determining characteristics of civilian GSW to the spine and identify the differences to the well-studied BT. PURPOSEThe aim of this study was to compare clinical characteristics, management, functional outcomes, and mortality associated with GSW to the spine versus BT. DESIGNRetrospective single-center analysis. PATIENT SAMPLEOne thousand nine hundred thirty-nine unique patients admitted to a level 1 trauma center with spinal cord injuries due to GSW or BT between the years 2003–2022. OUTCOME MEASURESPrimary outcome measure was the progression in American Spinal Injury Association (ASIA) motor score. METHODSClinical characteristics were compared followed by age-matched analysis (<45years) of neurological injury, the need for surgery, neurological outcomes and mortality. Stratification by neurological injury allowed for more homogenous subgroups for outcome analysis. RESULTSOf the 1939 patients with spinal cord injury, 566 were included in GSW group, and 1373 patients in BT group. Most patients in the GSW group were males (94.9% GSW vs. 83.5% BT; p<0.001) and younger (28.2 (range 13-62) years vs. 37.9, (range 12-91) years, p<0.001). The age-matched dataset comprised 1536 patients, with 540 in GSW group, and 996 in BT group. There were significantly more complete neurological injuries at admission in GSW group compared with BT (63.5% GSW vs. 34.4% BT, p<0.001). The ASIA motor Score at admission was significantly lower in GSW group (p<0.001), and changed without significant difference between the groups from admission to discharge (p<0.001, p=0.222). Subgroup analysis based on spinal cord injury showed that a higher proportion of patients with incomplete injuries improved neurologically, opposed to complete injuries, with significantly more patients improving in GSW group compared to BT (incomplete 58.9% GSW vs. 44.3% BT, p<0.001). Likewise, a higher proportion of paraplegic patients improved, opposed to quadriplegic patients, and in the paraplegic subgroup GSW patients improved rather than BT (paraplegic 65.1% GSW vs. 35.3%BT, p<0.001). In GSW group significantly less patients were managed operatively compared to BT group (12.2% GSW vs 76.8% BT, p<0.001). Most surgeries were bullet removals (81,4%) and involved the lumbar spine: 38.6% lumbar surgeries (of all GSW surgeries) and 31.4% surgery rate of all lumbar GSW patients. There was no significant difference in ASIA motor and sensory score improvement between patients who underwent surgery for bullet removal compared to nonoperatively managed patients in GSW group (p=0.199). The incidence rate of surgery showed a downwards trend over the study period. GSW group showed significantly less complications than BT group (22.8% GSW vs 27.0% BT, p<0.001). There was no significant difference in mortality rates (p ≥ 0.289). ConclusionTo our knowledge, this is the largest single-center dataset of civilian ballistic spinal cord injuries compared to BT. GSW affect mostly young males and result in significantly more severe, complete neurologic injuries compared with BT at similar mortality rates. Nevertheless, the present data suggest a greater potential for neurological improvement for paraplegic patients and incomplete injuries in GSW group. Patients with spinal cord injuries due to GSW undergo surgery less frequently compared to BT. Operated GSW cases primarily involved the lumbar spine. This study revealed differences between spinal cord injuries due to GSW and BT. In clinical application, this means that guidelines based on BT may not directly be transferable to civilian ballistic spinal cord injuries.

Low-Velocity Ballistic Trauma–Related Upper Extremity Nerve Injury: A Systematic Review and Meta-Analysis

Purpose: Optimal management of upper extremity nerve palsy caused by low-velocity ballistic trauma (LBT) remains controversial. The aim of this systematic review was to summarize the available evidence on the management of nerve injuries caused by LBT to the upper extremity. Methods: A literature search was completed for the keywords “Upper extremity,” “Nerve Injury,” and “Ballistic.” 2 independent reviewers conducted a systematic screening of all articles and collected data from relevant publications. The data were summarized and pooled using a random-effect model. Results: 14 studies met inclusion criteria. Cohorts between 6 and 168 patients (n = 848) with upper extremity LBT were reported. Neurologic deficits were present in 45% (95% CI: 38 to 52%) of patients at the time of injury evaluation. Nerve exploration was done in 50% (95% CI: 27 to 73%) of these patients with neurologic deficits. Early nerve exploration was done in 19% (95% CI: 9 to 32%) of all patients. Surgical findings included nerve continuity (49%; 95% CI: 14 to 84%), nerve contusion (30%; 95% CI: 12 to 50%), and nerve transection (31%; 95% CI: 14 to 50%). Nerve transection rates found at the time of exploration ranged from 0 to 71% (mean 31%). Outcomes were good in 62% (95% CI: 41 to 81%); however, analyses were limited by subjective outcome reporting of the studies. Conclusions: Contrary to historical teaching that LBT causes neurapraxia, this review identified that 31% of resulting nerve injuries were neurotmesis (transections). These results advocate for systematic clinical follow-up and appropriately timed nerve intervention (within 3 to 6 months of injury) when neurologic deficits persist after ballistic injury. Level of evidence: Level III

The Impact of Area Deprivation Index, Geography, and Mechanism on Incidence of Ballistic Injury to the Upper Extremity.

This study investigates the intersection of ballistic injuries, geography, and Area Deprivation Index (ADI). We hypothesized that both ADI and geography are correlated with incidence of upper extremity ballistic injuries. Further, we characterize and compare 2 distinct upper extremity gunshot injury populations presenting to our institution: those sustaining violent ballistic injuries and those who suffer an accidental, self-inflicted injury. Our purpose is to evaluate the impact of geography and ADI on the pattern of upper extremity gunshot injuries in Illinois and Missouri. This was a retrospective review of adult patients sustaining ballistic injury to the upper extremity at a single urban level I trauma center over 10 years (n = 797). Seven hundred thirty patients had home addresses in Illinois or Missouri; these addresses were geocoded and included for analysis. Mechanism of injury was self-reported. ADI was measured from the 2019 Neighborhood Atlas, in which deprivation increases from 1 to 100. Comparisons between groups were conducted with unpaired t tests, Fisher exact test, or χ2 testing, where appropriate. Addresses constituted 259 unique census tracts, and the average number of upper extremity gunshot wound incidents per tract was 3, with a maximum of 22; 15.4% of census block tracts made up almost half (48.4%) of the total ballistic injuries in the study period; 97.7% of violent injuries occurred in Urban areas, as compared with only 60% of accidental injuries (P < 0.05). ADI and incidence of upper extremity ballistic injury were positively correlated. ADI varied significantly between patients sustaining violent (median, 94; mean, 86.1) versus accidental self-inflicted (median, 79; mean, 70.9) injuries (P < 0.05). Fifty percent of violent injuries in our data set occurred in block groups from the 2 most deprived quintiles. Upper extremity gunshot wounds in general are concentrated in census blocks with high ADI. Violent injuries in particular are more likely to occur in urban areas with high ADI, whereas patients with accidental, self-inflicted injuries are more geographically and socioeconomically diverse. These differing populations require unique approaches to reduce incidence and morbidity.

Projectile Ballistic Injury to the Right Chest: A Life-Threatening Complication of a Firecracker

Projectile Ballistic Injury to the Right Chest: A Life-Threatening Complication of a Firecracker

Long-term results of treatment of Gustilo-Anderson type 3A-B tibia fractures due to combat-related high-energy ballistic injuries treated with external circular fixator: Experience of the Military Medical Academy.

The aim of this study was to evaluate the longterm outcomes of open tibia fractures treated using the Ilizarov external circular fixation (ECF) technique in the Military Medical Academy. Between January 1992 and December 2011, a total of 134 male military personnel (median age: 22.5 years; range, 18 to 36 years) with Gustilo-Anderson type 3 open tibia fractures treated with ECF were retrospectively analyzed. All patients underwent multiple surgeries and eventually Ilizarov fixation surgery. The radiological and functional outcomes were evaluated using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria, and complications were noted. The median follow-up was 17.7 (range, 10 to 29) years. The median time to union was 4.7 (range, 3 to 8) months. All frames were removed from the limb, when union was observed. No re-fracture, limb length discrepancy more than 2.5 cm, or below-knee amputation after Ilizarov treatment was seen in any patient. Chronic osteomyelitis was observed at in 40% (n=54) of the patients at a median time ranging from 17 to 148 months. The overall ASAMI bone scores were excellent in 40 (30%), good in 20 (15%), fair in 20 (15%), and poor in 54 (40%) patients with osteomyelitis. The ASAMI functional scores were excellent in 40 (30%), good in 40 (30%), and fair in 54 patients (40%). No poor score was observed. Minor pin site infections were observed in 63 patients (47%). Our long-term study results showed that all patients returned to their social life and were mobilized without support after treatment with the use of Ilizarov ECF method of open tibia fractures caused by high-energy ballistic injuries. However, complications such as pin tract infections and osteomyelitis after several years must be kept in mind in the treatment of comminuted bone fractures caused by firearms and ballistic missiles injuries.

Upper Extremity Ballistic Nerve Injury

» Gunshot injuries to the upper extremity (UE) have high likelihood for causing peripheral nerve injury secondary to the high density of vital structures. Roughly one-fourth of patients sustaining a gunshot wound (GSW) to the UE incur a nerve injury. Of these nerve injuries, just over half are neurapraxic. In cases of surgical exploration of UE nerve injuries, nearly one-third demonstrate a transected or discontinuous nerve.» Existing literature regarding surgical management of nerve injuries secondary to GSWs comes from both military and civilian injuries. Outcomes are inconsistently reported, and indications are heterogeneous; however, reasonable results can be obtained with nerve reconstruction.» Our proposed management algorithm hinges on 4 treatment questions: if there is a nerve deficit present on examination, if there is a concomitant injury in the extremity (i.e., fracture or vascular insult), whether the injured nerve would be in the operative field of the concomitant injury, and whether there was an identified nerve lesion encountered at the time of surgery by another surgeon?» Early exploration rather than continued expectant management may offer improved recovery from GSW nerve injuries in particular situations. When an UE nerve deficit is present, establishing follow-up after the initial GSW encounter and early referral to a peripheral nerve surgeon are pivotal.

The ballistic articular structure injury classification (BASIC) system: clarifying ballistic articular injuries.

This study aims to (1) devise a classification system to categorize and manage ballistic fractures of the knee, hip, and shoulder; (2) assess the reliability of this classification compared to current classification schemas; and (3) determine the association of this classification with surgical management. We performed a retrospective review of a prospectively collected trauma database at an urban level 1 trauma centre. The study included 147 patients with 169 articular fractures caused by ballistic trauma to the knee, hip, and shoulder. Injuries were selected based on radiographic criteria from plain radiographs and CT scans. The AO/OTA classification system's reliability was compared to that of the novel ballistic articular injury classification system (BASIC), developed using a nominal group approach. The BASIC system's ability to guide surgical decision-making, aiming to achieve stable fixation and minimize post-traumatic arthritis, was also evaluated. The BASIC system was created after analysing 73 knee, 62 hip, and 34 shoulder fractures. CT scans were used in 88% of cases, with 44% of patients receiving surgery. The BASIC classification comprises five subgroups, with a plus sign indicating the need for soft tissue intervention. Interrater reliability showed fair agreement for AO/OTA (k = 0.373) and moderate agreement for BASIC (k = 0.444). The BASIC system correlated strongly with surgical decisions, with an 83% concurrence in treatment choices based on chart reviews. Conventional classification systems provide limited guidance for ballistic articular injuries. The BASIC system offers a pragmatic and reproducible alternative, with potential to inform treatment decisions for knee, hip, and shoulder ballistic injuries. Further research is needed to validate this system and its correlation with patient outcomes. Level III, Diagnostic Study.

Understanding post-impact biomechanics of ballistic cranial injury by smoothed particle hydrodynamics numerical modelling

AbstractVirtual crime scene investigation using numerical models has the potential to assist in the forensic investigation of firearm-related fatalities, where ethical concerns and expensive resources limit the scope of physical experiments to comprehend the post-impact biomechanics comprehensively. The human cranial numerical model developed in this study incorporates three main components (skin, skull, and brain) with dynamic biomaterial properties. The virtual model provides valuable insights into the post-impact biomechanics of cranial ballistic injuries, particularly in high-speed events beyond conventional investigative capabilities, including the velocity of ejected blood backspatter, cavitation collapsing, and pressure waves. The validation of the numerical model, both quantitatively and qualitatively, demonstrates its ability to replicate similar bone fractures, entrance wound shapes, and backward skin ballooning observed in physical experiments of the human cranial geometry. The model also yields similar temporary cavity sizes, wound sizes, and blood backspatter time against the physical cranial model, aiding in bloodstain pattern analysis. Additionally, the numerical model enables exploration of ballistic factors that vary in each crime scene environment and influence cranial injuries, such as projectile type, velocity, impact location, and impact angle. These established injury patterns contribute to crime scene reconstruction by providing essential information on projectile trajectory, discharge distance, and firearm type, assisting in the resolution of court cases. In conclusion, the developed human cranial geometry in this study offers a reliable tool for investigating firearm-related cranial injuries, serving as a statistical reference in forensic science. Virtual crime scene investigations using these models have the potential to enhance the accuracy and efficiency of forensic analyses.

Utility of CT Scans for Detecting Operative Malleolar Fractures Associated With Tibial Shaft Fractures.

The purpose of this study was to define the utility of CT scans for detecting articular extension in tibial shaft fractures and determine whether radiographic parameters can predict the presence of operative distal tibial articular fractures (DTAFs). Retrospective cohort study. Single level I trauma center. Patients age 18 years and older who were treated operatively for tibial shaft fractures occurring at or below the tibial isthmus were included. Patients were excluded for extension of the main tibial shaft fracture into the tibial plafond (AO/OTA 43 B/C), ballistic injuries, and absence of a preoperative CT scan. The primary outcome was CT utility, defined as the presence of a DTAF or DTAF displacement on CT that was not recognized on plain radiographs on secondary analysis at the time of the study by a senior-level resident. Secondary outcome was the association between radiographic parameters and operative DTAFs. Variables with P ≤ 0.2 on univariate testing were included in a multiple binary logistic regression model to determine independent predictors of operative DTAFs. One hundred forty-four patients were included, with a mean age of 52 years. Seventy-six patients (53%) were men. CT utility was 41% for the identification of unrecognized DTAFs. CT utility was 79% for isolated pDTAF, 57% for medial DTAF, 83% for isolated anterolateral DTAF, and 100% for multiple DTAFs. Operative DTAFs were independently associated with spiral tibial shaft fracture type (P < 0.001) and low fibular fracture (P = 0.04). In patients who had both spiral tibial shaft fracture type and low fibula fracture, the rate of operative DTAF was 46% (22/48). CT scans identified DTAFs that were unrecognized on plain radiographs in 41% of cases. CT scans were most useful in identifying nonposterior DTAFs. CT scans may be considered for all distal third tibial fractures, but especially those with spiral tibial shaft patterns and low fibular fractures, to avoid missing operative articular injury. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Epidemiology of Pediatric Firearm Injuries in the United States: The Progression of Gunshot Injury Rates Through the Coronavirus Disease 2019 Pandemic.

Ballistic injuries among pediatric populations have become a public health crisis in the United States. The surge in firearm injuries among children has outpaced other causes of death. This study aims to assess the trend in pediatric gunshot injuries (GSIs) over the last decade and investigate the impact, if any, of the pandemic on GSIs statistics. A comprehensive retrospective analysis was conducted using a federated, real-time national database. A total of 15,267,921 children without GSIs and 6261 children with GSIs between 2017 and 2023 were identified. The study evaluated the incidence and annual proportions of GSIs among different demographics. In addition, the incidence proportions per 100,000 for accidental, nonaccidental, fracture-related, and fatal GSIs were analyzed. The incidence proportions per 100,000 for GSIs, accidental GSIs, nonaccidental GSIs, fatal GSIs, wheelchair-bound cases, and fracture-related GSIs increased significantly from 2017 to 2023, going from 9.7 to 22.8 (Relative Risk: 2.342, 95% CI: 2.041, 2.687 , P < 0.001). The overall increase was mostly a result of accidental GSI when compared with nonaccidental (incidence proportion 25.8 vs 2.1; P < 0.001) in 2021 at the height of the pandemic. In patients with an accidental GSI, the incidence proportion per 100k between 2017 and 2023 increased from 8.81 to 21.11 (Relative Risk: 2.397, 95% CI: 2.076, 2.768, P < 0.001). The study supports the shift in the leading cause of death among children from motor vehicle accidents to GSIs, with the continued rise in rates despite the coronavirus disease 2019 pandemic. Accidental injuries constituted the majority of GSIs, indicating the need for enhanced gun safety measures, including requirements for gun storage, keeping firearms locked and unloaded, requiring child supervision in homes with guns, and enforcing stricter punishments as penalties. Comprehensive efforts are required to address this public health crisis. Pediatricians play a vital role in counseling and educating families on firearm safety. Level III.

The deceleration of full metal jacket bullets in compact target models – A new approach

The wounding potential of a projectile depends on its kinetic energy. The aim of the study was to investigate the deceleration of non-deforming full metal jacket handgun bullets (FMJ) in gelatine blocks of increasing length. The temporary cavity (TC) was visualized using a SA-X2 Photron camera.126 test shots in 9 mm nominal calibre were fired under strict temperature control conditions (4°C) at small gelatine blocks ranging from 2 to 12 cm in length. The deposited energy was calculated based on the loss of bullet velocity through high-speed video analysis. The length of the TC was measured, when the TC reached its maximum height. The volume of the TC was approximated by a cylinder.Regression analysis showed a linear correlation between the length of the bullet path and the energy transfer. The constant deceleration of the FMJ bullets in gelatine up to 12 cm bullet path was confirmed across various brands and velocity ranges (270–450 m/s). Higher impact velocities correlated with increased loss of energy in the target medium. The shape of the bullet tip influenced the characteristic of deceleration. The volume of the tubular temporary cavity, derived from high-speed video records, was found to be proportional to the energy transferred.The proposed approach might be a valuable tool in advancing wound ballistics research.

Injuries in Fatalities of Dismounted Blast: Identification of Four Mechanisms of Head and Spine Injury.

Blast is the most common injury mechanism in conflicts of this century due to the widespread use of explosives, confirmed by recent conflicts such as in Ukraine. Data from conflicts in the last century such as Northern Ireland, the Falklands, and Vietnam up to the present day show that between 16% and 21% of personnel suffered a traumatic brain injury. Typical features of fatal brain injury to those outside of a vehicle (hereafter referred to as dismounted) due to blast include the presence of hemorrhagic brain injury alongside skull fractures rather than isolated penetrating injuries more typical of traditional ballistic head injuries. The heterogeneity of dismounted blast has meant that analysis from databases is limited and therefore a detailed look at the radiological aspects of injury is needed to understand the mechanism and pathology of dismounted blast brain injury. The aim of this study was to identify the head and spinal injuries in fatalities due to dismounted blast. All UK military fatalities from dismounted blast who suffered a head injury from 2007-2013 in the Iraq and Afghanistan conflicts were identified retrospectively. Postmortem computerized tomography images (CTPMs) were interrogated for injuries to the head, neck, and spine. All injuries were documented and classified using a radiology brain injury classification (BIC) tool. Chi-squared (χ2) and Fisher's exact tests were used to investigate correlations between injuries, along with odds ratios for determining the direction of correlation. The correlations were clustered. There were 71 fatalities from dismounted blast with an associated head injury with a CTPM or initial CT available for analysis. The results showed the heterogeneity of injury from dismounted blast but also some potential identifiable injury constellations. These were: intracranial haemorrhage, intracranial deep haemorrhage, spinal injury, and facial injury. These identified injury patterns can now be investigated to consider injury mechanisms and so develop mitigation strategies or clinical treatments. Level of Evidence: Observational. Study type: cohort observational.

Place of Delayed Primary Closure in Ballistic Wounds and by Explosive Devices at the Somine Dolo Hospital in Mopti

Objectives: To study delayed primary closure in ballistic and explosive device injuries by describing the clinical, therapeutic and evolutionary aspects. Methodology: This was a prospective study running from August 1, 2022 to May 31, 2023 including all patients of all ages presenting a ballistic or explosive device injury. Results: In 10 months, we collected 190 cases of ballistic and explosive device trauma, or 35.9%. The average age was 31.89 ± 14.026 years with a sex ratio of 12. Intercommunity conflicts were the most frequent causes (61.1%). Limb injuries represented 78.9 %, of which isolated wounds without fracture were the most frequent (59.5%). Standard radiography was ’the most used medical imaging (94%). DPC (Deferred Primary Closure) was performed in 71.2% followed by DPC + external fixator in 19%. We recorded 2 cases of death. Conclusion: Well-conducted delayed primary closure helps reduce the risk of complications, give the patient every chance of survival and shorten the hospital stay.

Civilian Ballistic Injuries to the Atlantoaxial Spine: A Single Institution Case Series.

Retrospective case series. Describe the injury characteristics of ballistic fractures involving the atlantoaxial spine. Civilian gunshot wounds to the spine are an increasingly common injury in the United States. Civilian studies have focused on ballistic injuries to the entire spine as opposed to a region-specific fashion. Only a single 10-patient case series investigating ballistic fractures to the upper cervical spine (C1 and C2) exists, leaving a large gap in the understanding of this injury complex. A retrospective chart review was performed. Extracted data included patient demographics, neurological status on presentation, fracture morphology, assessment of stability, other associated injuries, and surgical procedures performed. Proportional analysis was performed to characterize the fractures and their associated neurological injuries. Thirty-six patients were identified, with 86% being male with an average patient age of 30.0 ± 10.36 years (mean ± SD). Fracture morphology was characterized using proportional analysis. Initial neurological exams were either ASIA A or ASIA E, without any incomplete injuries noted. Patients who sustained a transcanal injury did not show any neurological improvement. The initial in-hospital mortality rate was 5.6%, with a 1-year mortality rate of 8.3%. There is a high incidence of associated vascular injury (66%) and mandible fracture (33%). Ballistic penetrating trauma to the atlantoaxial spine often results in complex injury patterns necessitating multidisciplinary care with high rates of morbidity and mortality. If neurological deficits are present initially, they are often complete. Two thirds of patients sustained an associated vascular injury, which should be screened for with CT angiography.

Skin simulants for wound ballistic investigation – an experimental study

Gunshot wound analysis is an important part of medicolegal practice, in both autopsies and examinations of living persons. Well-established and studied simulants exist that exhibit both physical and biomechanical properties of soft-tissues and bones. Current research literature on ballistic wounds focuses on the biomechanical properties of skin simulants. In our extensive experimental study, we tested numerous synthetic and natural materials, regarding their macromorphological bullet impact characteristics, and compared these data with those from real bullet injuries gathered from medicolegal practice. Over thirty varieties of potential skin simulants were shot perpendicularly, and at 45°, at a distance of 10 m and 0.3 m, using full metal jacket (FMJ) projectiles (9 × 19 mm Luger). Simulants included ballistic gelatine at various concentrations, dental silicones with several degrees of hardness, alginates, latex, chamois leather, suture trainers for medical training purposes and various material compound models. In addition to complying to the general requirements for a synthetic simulant, results obtained from dental silicones shore hardness 70 (backed with 20 % by mass gelatine), were especially highly comparable to gunshot entry wounds in skin from real cases. Based on these results, particularly focusing on the macroscopically detectable criteria, we can strongly recommend dental silicone shore hardness 70 as a skin simulant for wound ballistics examinations.

Management of Ballistic Injuries Affecting the Limbs at the University Hospital of Tengandogo, Burkina Faso, West Africa

Abstract Introduction: Limb arterial injuries are serious clinical conditions that can lead to amputation or death. In Burkina Faso, there is a rise in gun shooting since 2016 because of armed conflict. In this study, the authors report the management of limb arterial injuries that occurred in ballistic traumas. Patients and Methods: From January 1, 2019, to December 31, 2022, 15 patients (14 males and 1 female) consecutively underwent operative management of limb arterial injuries at the University Hospital of Tengandogo. The mean age was 29.9 years old (17–55). Outcomes were defined according to intensive care unit stay time and postoperative morbidity and mortality. Results: Hospital admission after 6 h represented 93.7%. Unstable hemodynamic status was noted in 40%. Upper limbs arteries were more injured (60%) and these included false aneurysms (9) and complete arterial cut (6). Revascularization techniques consisted of direct suture in eight cases and prosthetic grafting in seven cases. Postoperatively, five patients presented complications: two superinfections, two skin necrosis, and one limb paresis. Amputation and mortality were nil. Conclusion: The management of ballistic arterial trauma to the limbs is late in our context. Circumstances are dominated by combat injuries and the militaries are more affected. However, a good indication for revascularization and rigorously executed technique can save the limbs.

Lactic acid levels are associated with morbidity, length of stay, and total treatment costs in urban trauma patients with lower extremity long bone fractures.

Lactic acid is well studied in the trauma population and is frequently used as a laboratory indicator that correlates with resuscitation status and has thus been associated with patient outcomes. There is limited literature that assesses the association of initial lactic acid with post-operative morbidity and hospitalization costs in the orthopedic literature. The purpose of this study was to assess the association of lactic acid levels and alcohol levels post-operative morbidity, length of stay and admission costs in a cohort of operative lower extremity long bone fractures, and to compare these effects in the ballistic and blunt trauma sub-population. Patients presenting as trauma activations who underwent tibial and/or femoral fixation at a single institution from May 2018 to August 2020 were divided based on initial lactate level into normal, (< 2.5) intermediate (2.5-4.0), and high (> 4.0). Mechanism of trauma (blunt vs. ballistic) was also stratified for analysis. Data on other injuries, surgical timing, level of care, direct hospitalization costs, length of stay, and discharge disposition were collected from the electronic medical record. The primary outcome assessed was post-operative morbidity defined as in-hospital mortality or unanticipated escalation of care. Secondary outcomes included hospital costs, lengths of stay, and discharge disposition. Data were analyzed using ANOVA and multivariate regression. A total of 401 patients met inclusions criteria. Average age was 34.1 ± 13.0years old, with patients remaining hospitalized for 8.8 ± 9.5days, and 35.2% requiring ICU care during their hospitalization. Patients in the ballistic cohort were younger, had fewer other injuries and had higher lactate levels (4.0 ± 2.4) than in the blunt trauma cohort (3.4 ± 1.9) (p = 0.004). On multivariate regression, higher lactate was associated with post-operative morbidity (p = 0.015), as was age (p < 0.001) and BMI (p = 0.033). ISS, ballistic versus blunt injury mechanism, and other included laboratory markers were not. Lactate was also associated with longer lengths of stay, and higher associated direct hospitalization cost (p < 0.001) and lower rates of home disposition (p = 0.008). High initial lactate levels are independently associated with post-operative morbidity as well as higher direct hospitalization costs and longer lengths of stay in orthopedic trauma patients who underwent fixation for fractures of the lower extremity long bones. Ballistic trauma patients had significantly higher lactate levels compared to the blunt cohort, and lactate was not independently associated with increased rates of post-operative morbidity in the ballistic cohort alone. III.

Liar, liar, Pants on Fire’ – Management of Genitorinary Injury Sustained post ‘Cherry Bomb’ Explosion

Penile trauma comprised of 10-16% of genitourinary injury based on several single institution series [1]. Penetrating external genitalia trauma was 0.57%, of all trauma. 28% of it, was penile injuries, with concomitant urethra injuries occurred in 13% [2]. In ballistic injury, the penetrating wound could be superficial, however misleading and underrepresented of the actual extent of injury. Principle of treatment: immediate exploration, copious irrigation, excision of foreign matter, antibiotic prophylaxis and surgical closure [3]. The functional outcomes were excellent [4]. A case of 29 years old male with penetrating penile trauma with concomitant urethral trauma.

MODERN GLOBAL SCIENTIFIC TRENDS OF FORENSIC RESEARCH METHODS IN CASES OF FIREARM TRAUMA

This literature review aimed to investigate the new scientific trends in the methods concerning criminalistics in cases of firearm trauma. Articles on this topic published in the high-scoreforensic scientifi c journals between 2019-2023 years were analyzed. A literature search revealed the following major scientifi c areas of forensic science which are commonly developed today in cases of fi rearm trauma: fi rearm examination itself, shooting incident reconstruction and wound ballistics. A great importance of wound ballistics has underlined in the review. Basic studies on soft tissue simulants, main ways and methods in which radiology techniques can be applied during forensic medical and ballistic expertize were lightened too. Special attention in the article payed to molecular ballistics and ballistic head model.

DISCOVERY OF A NEW MORPHOLOGICAL FEATURE IN FORENSIC MEDICINE DURING THE STUDY OF GUNSHOT INJURY USING THREE-DIMENSIONAL MODELING OF THE WOUND CHANNEL

The use of spatial three-dimensional modeling of the main elements of a gunshot injury plays a significant part in the modern forensic medical examination. It allows not only to improve the visualization of such bodily injuries, to increase the objectivity and validity of expert conclusions, to accumulate an evidence basis for war crimes committed with the use of various types of firearms, but it also helps to discover new morphological features which couldn’t be detected when using traditional research methods. The work shows the process of detecting a new morphological feature during three-dimensional modeling of the wound channel caused by the IJ 70-01 pistol loaded with 9 mm cartridges.&#x0D; Aim of the work. Demonstration of new possibilities of three-dimensional spatial modeling in the process of the forensic investigation of a gunshot wound.&#x0D; Materials and methods. To achieve the aim of study, a series of experimental shots were fired from the IJ 70-01 automatic pistol loaded with 9 mm cartridges. To conduct bench ballistic tests according to the US standards – NIJ (National Institute of Justice), HOSDB (Home Office Scientific Development Branch) – standardized ballistic clay Roma Plastilina No.1 was used as the main material that absorbs the energy of the bullet and reproduces all the elements of wound ballistics. It was coated in pig skin with subcutaneous adipose tissue in order to recreate more true-to-life conditions of the gunshot injury. The generated wound channel was filled with Tropicalgin alginate impression material (Zhermack, Italy), which was mixed according to the manufacturer’s instructions; it has short setting time and reproduces the smallest details of the wound channel. Thereafter, the formed cast of the wound channel was subjected to a series of photographs at the appropriate angles and its 3D model was created with the help of the graphic design software “Agisoft PhotoScan” and “3ds max”.&#x0D; Results. The result of the conducted studies was obtaining a spatial three-dimensional model of the gunshot wound channel, which brings about new opportunities for its research. The implementation of three-dimensional modeling techniques made it possible to discover a new morphological feature – a helical torsion of the wound channel, the direction of which can indicate specific design features of the firearm used.&#x0D; Conclusions. The implementation of three-dimensional spatial modeling in the process of a gunshot trauma investigation sets conditions for increasing visibility and objectivity during conduction of such forensic medical examinations. At the same time, new opportunities are brought about for taking linear dimensions of the existing morphological features of the wound channel main elements with extended precision, the accumulation of demonstrative evidence basis in cases of such injuries, and the discovery of new morphological features for identification of the specific design features of the firearm used.