High Velocity Missile Injury Research Articles

Complications, outcomes, and management strategies of non-missile penetrating head injuries.

While high-velocity missile injury (gunshot) is associated with kinetic and thermal injuries, non-missile penetrating head injury (NMPHI) results in primary damage along the tract of the piercing object that can be associated with significant secondary complications. Despite the unique physical properties of NMPHI, factors associated with complications, expected outcomes, and optimal management have not been defined. In this study, the authors attempted to define those factors. Consecutive adult patients with NMPHI who presented to Tygerberg Academic Hospital (Cape Town, South Africa) in the period from August 1, 2011, through July 31, 2018, were enrolled in a prospective study using a defined treatment algorithm. Clinical, imaging, and laboratory data were analyzed. One hundred ninety-two patients (185 males [96%], 7 females [4%]) with 192 NMPHIs were included in this analysis. The mean age at injury was 26.2 ± 1.1 years (range 18-58 years). Thirty-four patients (18%) presented with the weapon in situ. Seventy-one patients (37%) presented with a Glasgow Coma Scale (GCS) score of 15. Weapons included a knife (156 patients [81%]), screwdriver (18 [9%]), nail gun (1 [0.5%]), garden fork (1 [0.5%]), barbeque fork (1 [0.5%]), and unknown (15 [8%]). The most common wound locations were temporal (74 [39%]), frontal (65 [34%]), and parietal (30 [16%]). The most common secondary complications were vascular injury (37 patients [19%]) and infection (27 patients [14%]). Vascular injury was significantly associated with imaging evidence of deep subarachnoid hemorrhage and an injury tract crossing vascular territory (p ≤ 0.05). Infection was associated with delayed referral (> 24 hours), lack of prophylactic antibiotic administration, and weapon in situ (p ≤ 0.05). A poorer outcome was associated with a stab depth > 50 mm, a weapon removed by the assailant, vascular injury, and eloquent brain involvement (p ≤ 0.05). Nineteen patients (10%) died from their injuries. The Glasgow Outcome Scale (GOS) score was linearly related to the admission GCS score (p < 0.001). One hundred forty patients (73%) had a GOS score of 4 or better at discharge. The most common NMPHI secondary complications are vascular injury and infection, which are associated with specific NMPHI imaging and clinical features. Identifying these features and using a systematic management paradigm can effectively treat the primary injury, as well as diagnose and manage NMPHI-related complications, leading to a good outcome in the majority of patients.

Retained Piece of Motorized Wood Cutter Blade Causing Transorbital Intracranial Injury: A Modern Industrial Hazard

Penetrating injury of brain is potentially life threatening. Majority of such injury is caused by high-velocity missile injury, unlike to civilian injury being caused by low velocity. Penetrating object getting entry through transorbital route is considered rarer with few published reports in literature. Penetrating objects can be made up of metal, glass, or even wood. Patient can seek medical advice immediately or after some delay. Authors report a case, who rushed to hospital immediately after sustaining injury by broken piece of motorized wooden cutting blades. He underwent surgery for removal of foreign body and tolerated surgery well. Proper elicitation of clinical history, neurological examination, and timely appropriate neuroimaging and expeditious surgical treatment are crucial and can be helpful in generating exceptionally good outcomes despite a major trauma. Pertinent literature is briefly reviewed.

Endotracheal intubation in the prone position, in a patient with a high-velocity missile injury to the abdomen and thorax

The airway management in prone position secondary to penetrating posterior thoracic injury is challenging to the anesthetist. We described a successful endotracheal intubation under direct laryngoscopy at first attempt in the prone position in a 25-year-old male with a 6-foot hollow metal impacted in the right posterolateral thorax.

Low velocity penetrating head injury with impacted foreign bodies in situ

Penetrating head injury is a potentially life-threatening condition. Penetrating head injuries with impacted object (weapon) are rare. The mechanism of low velocity injury is different from high velocity missile injury. Impacted object (weapon) in situ poses some technical difficulties in the investigation and management of the victims, and if the anticipated problems are not managed properly, they may give rise to serious consequences. The management practice of eight patients with impacted object in situ in context of earlier reported similar cases in literature is presented.

Complex Regional Pain Syndrome Type II Associated with Lumbosacral Plexopathy: A Case Report

Complex regional pain syndrome (CRPS) is a well-known clinical entity, first described in the 1800s, consisting of pain, hyperalgesia, edema, and sudomotor changes either without (Type I) or with (Type II) a definable nerve injury. CRPS Type II is most commonly caused by high velocity missile injuries, mononeuropathies, and partial nerve transections. In this case, a 25-year-old soldier who sustained a blast injury causing multiple spinal compression fractures, extremity fractures, and pelvic and sacral fractures was transferred to a U.S. Army medical center for surgical management and rehabilitation. He complained of weakness, sensory changes, and pain in his left lower extremity. The patient also demonstrated swelling and hyperesthesia of the left foot and ankle. Undiagnosed soft tissue injury, fracture, and deep venous thrombosis were ruled out by imaging studies. The patient had an electromyogram/nerve conduction study (EMG/NCS) that showed widespread left sided lumbosacral plexopathy as well as possible cauda equina injury. Triple phase bone scan demonstrated findings consistent with CRPS of the left foot and ankle. He was started on a tricyclic antidepressant and an anticonvulsant. Physical and occupational therapy were quickly engaged to incorporate range of motion exercises, mirror therapy, and physical modalities. The patient continued conservative management and rehabilitation and eventually was discharged with significantly improved function and decreased pain. Although many causes of CRPS Type II have been described, this is only the second reported case of CRPS Type II secondary to lumbosacral plexopathy in the literature.

War injuries of the crural arteries.

Twenty-eight patients with military crural vascular injuries are presented. In the group undergoing immediate repair (21 patients), the time interval between trauma and surgery was 20 min to 30 h (mean 8 h 30 min). In those receiving delayed repair (seven patients), the interval between trauma and surgery was 3-47 (mean 14) days. Hyperbaric oxygenation therapy was used in conjunction with surgery and antibiotic therapy in 13 of the 28 patients. Explosive injuries were found in 14 patients and high-velocity missile injuries in nine; associated fractures were present in 20. Twenty of the 28 patients with crural vascular injuries had combined arterial and venous injuries, while eight had isolated arterial injuries. Twenty-five patients with distal ischaemia required arterial repair; five late amputations resulted. Military crural vascular injuries should be treated with soft tissue debridement, removal of foreign material, and microvascular arterial and concomitant vein reconstruction. This should be followed by external skeletal stabilization for bony and/or soft tissue instability, with fasciotomy for any associated compartment syndrome. The wound should be left open, with delayed closure or split skin grafting. It was felt that hyperbaric oxygen therapy reduced the amputation rate following combat-related crural vessel injuries.

High Velocity Missile Wounds. M. S. Owen-Smith. 235 × 156mm. Pp. 182 + x. Illustrated. 1981. London: Arnold. £12·75

High Velocity Missile Wounds. M. S. Owen-Smith. 235 × 156mm. Pp. 182 + x. Illustrated. 1981. London: Arnold. £12·75

Missile injuries of the abdomen in Zimbabwe-Rhodesia.

One hundred and thirteen patients with missile injuries of the abdomen were seen over a 3-year period at one hospital in Zimbabwe-Rhodesia. The details of these injuries and the results of their treatment are presented. Twenty-four patients died (21 per cent). Twenty of these patients had sustained high velocity missile injuries, 18 had damaged colons and 3 died from major vascular injuries before surgery. Excluding these last 3 patients, the mortality rate for high velocity wounds of the colon was 52 per cent and that for all other patients was 6 per cent (P less than 0.01). More than half the postoperative deaths were due to septicaemia. The importance is stressed is stressed of early and effective resuscitation, including appropriate antibiotic therapy and rapid evacuation to facilities for major surgery.

The management of pancreatic and pancreaticoduodenal injuries.

Abstract From 1969 to 1979 39 injuries of the pancreas and duodenum were treated at the Royal Victoria Hospital, Belfast. The mortality was 31 per cent. Twenty-six injuries were due to stab, bomb or bullet. Two of the 17 with low velocity gunshot wounds died, whereas all 5 cases of high velocity missile injury died (P &amp;lt; 0·001). Ten of the 13 cases of blunt trauma were due to road traffic accidents. In 21 cases the body and tail of the gland were injured, and in 13 the head and neck. There were 5 isolated duodenal injuries and in 7 a combined pancreaticoduodenal injury. The mortality was directly related to the number of other organs damaged. Three main methods of treatment were used—simple drainage, suture and drainage, and primary distal pancreatic resection. Serious complications, pancreatitis, fistula, secondary haemorrhage and sepsis were frequent after the first two methods but rare after distal resection. Diagnosis was delayed in 4 cases of closed injury and 1 of these patients died. Pancreatic injury was missed 6 times at operation; in 4 cases retroperitoneal haematoma was not explored and 2 of these patients died. Five of the 12 deaths were due to overwhelming bomb and bullet injury. In one case resuscitation was inadequate. The remaining 6 died of the complications of the original pancreatic injury, either because operation was delayed or because the injury was missed. Our management was deficient in three areas: awareness of the need for laparotomy, recognition of the injury at operation and inadequate surgery. All open abdominal injuries must be explored; suspicion and careful assessment are essential in closed trauma. At operation the pancreas must be carefully examined; an upper retroperitoneal haematoma is an absolute indication for this. Simple drainage is only sufficient for trivial injury; for major injury of the body and tail we prefer distal resection. Roux loop drainage is suggested for injury to the head and neck, especially when associated with duodenal injury.

External fixation device in treatment of the upper third femoral open fractures caused by firearms

Seventeen patients with open fractures of the upper third of the femur were treated using a pelvifemoral external fixation device. All of them had grade III open fractures resulting from high-velocity missile and explosive injuries with massive foreign body contamination. Sciatic nerve injury was present in five (29.4%); abdominal viscera and thoracic wall injuries were present in two patients (11.8%). There were no major arterial injuries. Full weight bearing was allowed after clinical and radiological bone healing (average 11.5 months). Chronic osteitis with fistula and sequestra developed in two (11.8%) patients. There were no nonunions and no refractures. Minor painless limitation of hip motion persisted in all patients. Upper-third femoral open fractures due to firearms are a unique type of open fractures. They are usually highly comminuted; therefore, stable fixation is difficult or impossible to achieve using external fixation with transfixation of the fracture site. On the other hand, the risk of infection is high following intramedullary nailing. Pelvifemoral external fixation allows adequate management of the soft tissue wounds, provides stable bone fixation and allows early patient mobilization.

External fixation war injuries of the proximal humerus

Nine patients with open fractures of the proximal humerus were treated using an external fixation device. All of them had grade III open fractures resulting from high-velocity missile and explosive injuries with massive foreign body contamination. Radial nerve injury was present in five and two multiply injured patients with thoracic wall and abdominal viscera were present. There were no major arterial injuries. Chronic osteitis with fistula and sequestra developed in one. There were no nonunions and no refractures. Minor painless limitation of shoulder and elbow motion presented in all patient. Upper-third humeral open fractures due to firearms are a unique type of open fractures. They are usually highly comminuted therefore, stable fixation is difficult or impossible to achieve. On the other hand, the risk of infection is high following plate fixation. External fixation allows adequate management of the soft tissue wounds, provides stable bone fixation and allows early mobilization of the shoulder and elbow.

Chorioretinitis sclopetaria

A variety of choroidal and retinal problems can result from direct, or coup type, trauma to the globe and these include retinal necrosis and atrophy, retinal breaks with or without retinal detachment, retinal dialysis, macular hole formation, choroidal rupture, chorioretinal scarring and commotio retinae [ 1 Dieckert J.P. Posterior segment trauma. in: Principles and practice of ophthalmolgy. vol. 5. WB Saunders, Philadelphia, PA1994: 3406 Google Scholar , 2 Sarin L.K. Reinert C.G. Retinopathy in ocular trauma. in: Duane's Clin. Ophthalmol.vol. 3. JB Lippincott, Philadelphia1992: 1-2 Google Scholar ]. Chorioretinitis sclopetaria, however, is unique to high velocity missile injuries which graze, but do not perforate, the sclera. In this report, we describe two cases of chorioretinitis sclopetaria and review the literature.

MR imaging of penetrating spinal trauma.

T he goals of treatment of acute spinal injury after penetrating trauma are to ensure stability of the spine, to minimize the extent of neurologic deficit, and to prevent further loss of neurologic function. MR imaging directly reveals the spinal cord parenchyma so that the radiologist can detect missile tracts, contusions, and hematomas resulting from direct cord penetration and indirect concussion effects from proximity high-velocity missile injuries. In addition, MR imaging can reveal cord compre ssion from extramedullary sources including hematoma, displaced bone or bullet fragments. and pseudomeningocele. Injuries to the spinal ligaments and vertebral arteries can also be seen on MR imaging F1 . 21. This pictorial essay reviews the spectrum of MR imaging pathology found with penetrating spinal injuries and discusses the influence of MR findings on patient treatment.

A gross and microscopic study of cerebral injuries accompanying maxillofacial high-velocity projectile wounding in dogs

Purpose: This study investigated the pathologic characteristics and some related factors of cerebral damage associated with maxillofacial high-velocity missile wounds. Materials and Methods: Sixty dogs, divided into two groups, were wounded randomly by steel spheres weighting 1.03 g at impact velocities of 1,400 m/s (46 dogs) and 800 m/s (14 dogs). Six dogs served as controls. The maxillofacial wounds and cerebral injuries were examined grossly. The distance between the center of wound and the base of skull and the largest diameter of the wound were measured, and the incidence of the brain injury in the two groups was compared. The cerebral specimens, dissected at 1 and 6 hours after trauma, were observed by light and electron microscopy. Results: Cerebral hyperemia, contusion, spotty hemorrhage, and intracerebral hematoma were found in some of the dogs. In the 1,400 m/s velocity missile wound group, the incidence of the brain injury was 71.7% (33 of 46), and in the 800 m/s group it was 7.1% (1 of 14) on macroscopic examination. Microscopic observation showed intracerebral microhemotomas and degeneration and necrosis of the nervous cells. Conclusion: High-velocity projectile maxillofacial wounds can induce associated brain injury.

Low-velocity gunshot wounds to the paranasal sinuses

There are more than 200 million private firearms in the United States today. Firearm-associated deaths are the second leading cause of mortality for men 1 to 38 years of age. There are many studies in the literature concerning the management of high-velocity gunshot injuries to the head and neck. However, there are no studies in the English language literature concerning the management of isolated low-velocity gunshot wounds to the paranasal sinuses. We retrospectively reviewed 35 patients treated for low-velocity gunshot wounds of the paranasal sinuses between 1985 and 1994 at Kings County Hospital Center. The injuries sustained by these patients were less severe than previously reported for high-velocity missile or shotgun injuries. The management of these injuries is outlined with emphasis on (1) indications for angiographic studies, (2) airway management, and (3) indications for operative removal of bullet fragments. (Otolaryngol Head Neck Surg 1997;116:372-8.)

Low-velocity gunshot wounds to the paranasal sinuses.

There are more than 200 million private firearms in the United States today. Firearm-associated deaths are the second leading cause of mortality for men 1 to 38 years of age. There are many studies in the literature concerning the management of high-velocity gunshot injuries to the head and neck. However, there are no studies in the English language literature concerning the management of isolated low-velocity gunshot wounds to the paranasal sinuses. We retrospectively reviewed 35 patients treated for low-velocity gunshot wounds of the paranasal sinuses between 1985 and 1994 at Kings County Hospital Center. The injuries sustained by these patients were less severe than previously reported for high-velocity missile or shotgun injuries. The management of these injuries is outlined with emphasis on (1) indications for angiographic studies, (2) airway management, and (3) indications for operative removal of bullet fragments.

The Late Treatment of 63 Overlooked or Complicated Ureteral Missile Injuries: The Promise of Nephrostomy and Role of Autotransplantation

Purpose Nephrostomy was emphasized as an initial treatment for ureteral fistulas, internal leakage (urinoma or urinary ascites) or ureteral obstruction due to a high velocity missile injury that was overlooked during the acute phase of management or manifested after primary surgery. Autotransplantation is introduced as an option for treatment of such late sequelae. We report a large series of complicated penetrating ureteral injuries of war. Materials and Methods A series of 63 patients with war related ureteral injuries secondary to high velocity missile wounds presented with external fistulas, internal leakage or ureteral obstruction. No patient presented in the acute phase of injury, and they were referred from frontline hospitals or other departments at our hospital. The ureteral injury was missed during exploratory laparotomy in 47 patients (75 percent), while 16 (25 percent) had undergone a primary ureteral procedure elsewhere. A total of 59 patients (94 percent) had associated injuries elsewhere in the body. Nephrostomy was performed initially in 51 patients (81 percent) and various reconstructions were done in 39, including autotransplantation 2. Results Leakage, internal or external, ceased in all 46 patients who underwent nephrostomy, of whom 20 (44 percent) had a patent ureter after 3 to 8 weeks and no further reconstruction was needed. Patients were followed for 13 to 24 months (average 15), after which they had a normal excretory urogram or mild residual dilatation of the pelvicaliceal system sterile urine. Two kidneys (3.2 percent of cases) were removed due to chronic sepsis. One patient (1.6 percent) died of septicemia related to the ureteral injury and 3 (5 percent) died of associated injuries although leakage had ceased. Both autotransplanted kidneys were normal. Conclusions When treating fistulas, urinomas, urinary ascites and obstruction due to a missed ureteral injury or a complication of the primary operation, the best results are achieved with initial nephrostomy followed by reconstruction when needed. Nephrostomy was a definitive treatment in 44 percent of our cases with leakage and it protected any required reconstruction. The option of autotransplantation for an otherwise unsalvagable kidney is emphasized.

THE MANAGEMENT OF WAR WOUNDS INVOLVING BONE

Over 200 high-velocity missile injuries treated in a low-technology environment were audited under the aegis of the International Committee of the Red Cross Hospitals in Afghanistan and Northern Kenya. Femoral fractures were treated either by traction or external fixation using a uniaxial frame. The results showed that patients treated by external fixation remained in hospital longer than those treated on traction. The positional outcome was identical in both groups. In tibial fractures the external fixator was only of extra benefit in those of the lower third when compared with simple plaster slabs unless more complex procedures such as flaps or vascular repair were to be performed. In complex humeral fractures, external fixation resulted in long stays in hospital and a large number of interventions when compared with simple treatment in a sling. We conclude therefore that in an environment where facilities are limited and surgeons have only general experience very careful initial wound excision is the most important factor determining outcome. The application of complex holding techniques was generally inappropriate.

Histologic and ultrastructural changes of the spinal cord after high velocity missile injury to the back.

Histologic and ultrastructural changes of the spinal cord after high velocity missile injury to the back.

High-velocity gunshot wound through bone with low energy transfer

It is recognized that high-velocity missile wounds may only produce a low energy transfer wound, but that high-velocity wounds involving bone invariably lead to high energy transfer, with consequent shattering of the bone. A case is presented where a high-velocity bullet passed through a long bone with low energy transfer, and where additionally the wound track was not visible on a plain radiograph. This has not been previously described. The pathophysiology and management of high-velocity gunshot wounds is briefly discussed; emphasis is given to adequate surgical treatment and wound closure by delayed primary suture.