Missile Injuries Research Articles

Management of Retained Foreign Bodies in Missile Injuries of the Maxillofacial Region

This study evaluates 22 patients with retained foreign bodies in the maxillofacial region that were all caused by penetrating missile injuries. Surgical intervention for the retrieval of the foreign bodies was carried out in 20 patients through the existing wounds and through separate incisions; all patients were followed up for a minimum of 2 months during which all the complications were registered and managed. Preoperative imaging is a prerequisite for the accurate localization of the foreign body and the subsequent successful removal of it. All patients developed complications that were categorized in this study into those that result from the injury itself and those that occur because of the retrieval procedure, the latter category being mostly easily managed. In general, all foreign bodies in the maxillofacial region should be removed; the surgeon involved should weigh the benefits and the perils of the removal, and the patient should be well informed about the possibility of the failure of removal of the foreign body.

Late sequelae of retained foreign bodies after world war II missile injuries

A number of people injured during the second world war harbour foreign bodies such as grenade splinters or bullets in some part of the body. Most of these metal fragments remain clinically silent. Some of them, however, may cause delayed complications.The purpose of this study was to determine the characteristics of delayed complications associated with foreign bodies after world war II injuries. 159 patients with retained foreign bodies after world war II injuries were retrospectively identified radiologically in our data bases in the time interval from 1997 to 2009. Diverse delayed complications secondary to the metal objects were diagnosed in 3 cases (2%): one patient with grenade splinter migration into the choledochal duct, one case with pseudotumoural tissue reaction, and one patient with late osteomyelitis. The time from injury to clinical presentation varied from 56 to 61 years. PubMed and Medline were screened for additional cases with delayed sequelae after foreign body acquisition during the 2nd world war. A 30 year search period from 1980 up to date was selected. 15 cases were identified here.Our study demonstrates that health consequences of the 2nd world war extend into the present time, and therefore physicians should be aware of the presence of hidden foreign bodies and their different possible late reactions.

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.

Evaluation of missile injuries in the Maxillofacial region in Mosul City-Iraq (2007-2011)

evaluation of missile injuries in the Maxillofacial region in Mosul City-Iraq (2007-2011)

Missile injury to the pediatric brain in conflict zones

This study was conducted both prospectively and retrospectively at one center over a period of 8 years. The population consisted of all patients with both an age 18 years or younger and a diagnosed penetrating missile injury (PMI) during the study interval. The authors analyzed factors determining outcome and demographic trends in this population, and they compared them with those in the more developed world. Fifty-one patients were the victims of armed conflict, although no one was directly a party to any battle. This mechanism of injury is in strong opposition to data in the literature from developed countries, in which most missile injuries are the result of suicide or homicide or are even sports related. Moreover, all previous studies on the pediatric population have considered only injuries from gunshots, but authors of the current study have included injuries from other penetrating missiles as well. On cross tabulation analysis using the chi-square test, the factors shown to correlate with outcome included the Glasgow Coma Scale (GCS) score, pupillary abnormalities, patient age, hemodynamic status, and bihemispheric damage. On multinomial regression analysis, the two strongest predictors of death were GCS score and pupillary abnormalities. The GCS score and hemodynamic status were the strongest predictors of disability. There was no difference in the prognostic factors for PMI between developing or more developed countries. Glasgow Coma Scale score, pupillary abnormalities, and hemodynamic status were the strongest predictors of outcome. In conflict zones in developing countries the victims were mostly innocent bystanders, whereas in the more developed countries homicides and suicides were the leading etiological factors.

Traumatic Middle Cerebral Artery Aneurysm Secondary to a Gunshot Wound

Traumatic intracranial aneurysms are rare lesions, accounting for less than 1% of all intracranial aneurysms. Formation of these lesions after a penetrating missile wound is very unusual, and diagnosis can be difficult due to the presence of associated lesions. In this article, we report a case of a woman who developed a middle cerebral artery aneurysm after a gunshot wound, and discuss potential pitfalls found during diagnostic work-up.

Profile of missile-induced cardiovascular injuries in Kashmir, India.

Background:Missile cardiovascular injuries have taken an epidemic proportion in Kashmir valley since the eruption of militancy in 1990. Present study was undertaken to analyse the pattern, presentation and management of missile cardiovascular injuries.Patients and Methods:Three hundred and eighty-six patients with missile cardiovascular injuries since Jan 1996 to Oct 2008 were studied retrospectively. All patients of cardiovascular injuries due to causes other than missiles were excluded from the study.Results:All patients of missile cardiac injuries were treated by primary cardiorrhaphy. Right ventricle was the most commonly affected chamber. Left anterior thoracotomy was most common approach used. Most of the patients of missile vascular group were treated by reverse saphenous vein graft or end-to-end anastomosis. Most common complication was wound infection (20.83%) followed by graft occlusion (1.94%) in missile vascular group. Amputation rate was 4.66%. Amputation rate was higher in patients with delay of >6 hours and associated fractures.Conclusion:Missile cardiac injuries should be operated early without wasting time for investigations. Clinical status at arrival, time interval till management, nature of injury and associated injuries, tell upon the mortality. Missile vascular injury needs prompt resuscitation and revascularization at the earliest. Time interval till revascularization and associated fractures has a bearing on mortality and morbidity.

What′s new in emergencies, trauma and shock? Mapping and managing missile injuries

What′s new in emergencies, trauma and shock? Mapping and managing missile injuries

Analytical review of 664 cases of penetrating buttock trauma

A comprehensive review of data has not yet been provided as penetrating injury to the buttock is not a common condition accounting for 2-3% of all penetrating injuries. The aim of the study is to provide the as yet lacking analytical review of the literature on penetrating trauma to the buttock, with appraisal of characteristics, features, outcomes, and patterns of major injuries. Based on these results we will provide an algorithm. Using a set of terms we searched the databases Pub Med, EMBASE, Cochran, and CINAHL for articles published in English between 1970 and 2010. We analysed cumulative data from prospective and retrospective studies, and case reports. The literature search revealed 36 relevant articles containing data on 664 patients. There was no grade A evidence found. The injury population mostly consists of young males (95.4%) with a high proportion missile injury (75.9%). Bleeding was found to be the key problem which mostly occurs from internal injury and results in shock in 10%. Overall mortality is 2.9% with significant adverse impact of visceral or vascular injury and shock (P < 0.001). The major injury pattern significantly varies between shot and stab injury with small bowel, colon, or rectum injuries leading in shot wounds, whilst vascular injury leads in stab wounds (P < 0.01). Laparotomy was required in 26.9% of patients. Wound infection, sepsis or multiorgan failure, small bowel fistula, ileus, rebleeding, focal neurologic deficit, and urinary tract infection were the most common complications. Sharp differences in injury pattern endorse an algorithm for differential therapy of penetrating buttock trauma. In conclusion, penetrating buttock trauma should be regarded as a life-threatening injury with impact beyond the pelvis until proven otherwise.

Non-metallic and metallic craniocerebral missile injuries: Varied outcome

We studied the comparative outcome related to 694 non-metallic and metallic craniocerebral missile injuries who lived at 2 hours and beyond the time of injury in a retrospective and prospective analysis in the Department of Neurosurgery at Sher-I-Kashmir Institute of Medical Sciences (SKIMS) Kashmir, India, over a period of 21 years from September 1988 to March, 2010. The study revealed an overall mortality of 32.70% (227 out of 694). A total of 664 adults and 30 children (mostly teenagers) were studied. The 79.1% (549 out of 694) patients were metallic missile injuries whereas 20.8% (145 out of 694) patients were non-metallic missile injuries. The non-metallic missile injury group mostly (72.4% i.e.; 105 out of 145) had low GCS score and overall worse prognosis with zero good-recovery, 47.5% disabilities and 52.4% mortality as compared to the metallic missile injury group. The non-metallic group comprised of 60% (18 out of 30) children with one death. Non-metallic missile injuries accounted for 10.95% (76 out of 694 patients) of total deaths. Predictors of poor outcome were low admission GCS score, non-metallic penetrating injury due to tear-gas cartridges, rubber bullets and stone-bullets, perforating metallic missile injuries and delayed and maltransportation. Most complications in non-metallic missile injuries were infective and had poor outcome. The common non-metallic missiles used were stone bullets (balls) fired by Gulail (modified catapult) or slingshot, red rubber bullets, plastic tear gas shells and cartridges, wooden (pulped mulberry stem) and card-board wads used in shotguns. The stone pelting, throwing stone projectiles (stone-bullets) by Gulail and manually has become a common way to inflict head injuries in Kashmir. The non-metallic missiles are not less-lethal and have high disabling, killing and infective potential.

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.

Nonmissile Penetrating Spinal Injury with an Impaled Knife: Case Report

We report a case of non missile penetrating spinal injury (NMPSI) caused due to an impaled knife in the lumbar region. The patient was neurologically preserved and presented with the knife blade retained in his back. The wound with the knife in situ was explored, the knife removed and a dural laceration was repaired. The wound healed without evidence for cerebrospinal fluid leakage or infection.

Upper and lower extremity nerve injuries in pediatric missile wounds: a selective approach to management

Nerve injuries from missile and gunshot wounds often produce significant disability, and their management is controversial. The role of the surgeon in cases of missile wounds with neurologic deficits is not well defined. Enhancing the trauma team's ability to recognize treatable nerve injuries will lead to improved outcomes. Further, raising awareness of the time-sensitive nature of these injuries will also improve results in these cases. We reviewed a consecutive series of 17 pediatric patients with peripheral nerve injuries caused by missile and gunshot wounds in a tertiary care children's hospital. We examined the indications for surgery, presence of associated injuries, mechanisms of injury, demographic characteristics and clinical outcomes. Urban victims were significantly more likely to have been intentionally assaulted than rural or suburban victims and they were also less likely to have completed follow-up care. High-energy weapons were more likely to require surgery compared with low-energy weapons. Patients presenting with tendon injuries were more likely to have a high-grade nerve injury requiring surgery. Patients presenting with tendon lacerations or high-energy mechanisms were significantly more likely to require surgery. Early exploration should be undertaken in cases where transection is likely to have occurred. Early decompression of common entrapment sites distal to repairs or injuries should be performed. Because follow-up is poor in this population, treatment should be prompt and thorough.

Polymorphisms in ion channel genes: emerging roles in pain

Why does one soldier, after sustaining a missile wound in the radial nerve on the battlefield, experience incapacitating neuropathic pain, while another, with a similar injury, complains of motor and sensory deficits in the absence of pain? Why is one patient with diabetic neuropathy disabled with neuropathic pain, while another patient with diabetic neuropathy of apparently similar severity experiences numbness or paraesthesias that are not painful? Pain is a complex phenomenon, mediated by transductive processes in the periphery, conduction to the spinal cord via first-order spinal sensory (dorsal root ganglion) neurons and processing at multiple higher levels that include the dorsal horn, thalamus and cortex. Multiple processes and molecules undoubtedly shape the perception of pain. Exciting progress, however, has recently been made in linking common variants of genes encoding two different ion channels within first-order sensory neurons along the pain pathway to inter-individual differences in pain. Discovery and characterization of these genetic variants, and of additional variants that will likely be identified in the future, open up the possibility of understanding more fully, at the molecular level, the processes that shape pain, and which may point the way to new therapeutic strategies. Ion channels play major roles in electrical signalling along the pain pathway; their central role in this process is underscored by the preferential expression within dorsal root ganglion neurons of three sodium channels, Nav1.7, Nav1.8 and Nav1.9, that are not expressed at high levels within the CNS (Cummins et al. , 2007). It is now well established that mutations of two ion channel genes can produce pain syndromes. The Nav1.7 sodium channel, which is preferentially expressed within dorsal root ganglion neurons including nocioceptors and sympathetic ganglion neurons (Djouhri et al. , 2003), displays slow inactivation in the closed-state near resting …

Management of civilian gunshot injuries to the extremities in Nigeria-an overview

There is an increasing incidence of missile injury attributable to improved technology, and increased crime and conflict rates in both developing and developed nations of the world. We undertook a review of civilian gunshot injuries to the extremities in Nigeria. The pathology of these injuries aswell as their implications for management are presented. The peculiar challenges they present to the orthopaedic surgeons in the management of gunshot injuries in a resource depleted country are highlighted. Community based socially and culturally acceptable conflict resolution mechanisms,control of fire arms and revision of the treatment guidelines are recommended as preventive and management strategies of gunshot injuries in Nigeria.

Reconstruction by Lateral Cervical Flap of Perioral and Oral Cavity

These clinical studies include 75 patients, followed up for 2 to 5 years: 37 females and 38 males. Age ranged between 5 and 81 years (median, 46 years). These cases were seen during a period of 6 years. There were 61 cases of oral squamous cell carcinoma; these cases include 25 cases of well-differentiated squamous cell carcinoma, 24 cases of moderately differentiated squamous cell carcinoma, and 12 cases of poorly differentiated squamous cell carcinoma. These cases were treated by adjuvant chemotherapy with radical surgery and deep x-ray therapy. In 23 cases, the lateral cervical flap (LCF) was used as an excess for radical resection of supraomohyoid neck dissection; in 10 cases, the LCF was used for reconstruction of cases with posttraumatic missile injuries, and in 4 cases, platysma muscle flap was used for reconstruction of underdeveloped masseter muscle in cases with mild hemifacial microsomia. Experimental studies were performed on rabbits for reconstruction of the lateral side of the tongue and submental region to assess the viability of LCF. In conclusion, the flap proved to be an ideal and most reliable flap for reconstruction of both perioral and oral defects after radical cancer surgery and posttraumatic missile injury deformities.

Dissecting firearm injury to the head and neck with non-linear bullet trajectory: A case report

Firearm injuries to the head and neck have a potential for fatal complications caused by damage to neurovascular structures in the region. We herewith present a case of a missile injury to the face, caused by a bullet from a rifle with high muzzle energy that slackened while penetrating a vehicle before hitting the victim. The bullet advanced through the retrofacial spaces following a non-linear course and was retained within the opposite parapharyngeal region without injuring any vital structure. The resultant damage was a ‘low-velocity injury’. However, it is noteworthy that the missile had still retained enough energy to penetrate the tissue and travel in a ‘dissecting’ fashion. It is likely that the blunting of the missile during vehicle penetration and the compactness of the anatomical structures bordering the head and neck spaces, such as fascia and tendons, forced the projectile to follow a non-linear inter-structural path. This case yet again demonstrates that the magnitude of firearm-related tissue damage may also depend upon the shape of the projectile and confirms that the head and neck spaces have anatomical integrity rather than just being arbitrarily designated topographical areas. It has also been confirmed that non-surgical approach with regular follow-ups is a viable option for uncomplicated head and neck injuries.

Penetrating head injury from angle grinder: A cautionary tale

Penetrating cranial injury is a potentially life-threatening condition. Injuries resulting from the use of angle grinders are numerous and cause high-velocity penetrating cranial injuries. We present a series of two penetrating head injuries associated with improper use of angle grinder, which resulted in shattering of disc into high velocity missiles with reference to management and prevention. One of those hit on the forehead of the operator and the other on the occipital region of the co-worker at a distance of five meters. The pathophysiological consequence of penetrating head injuries depends on the kinetic energy and trajectory of the object. In the nearby healthcare center the impacted broken disc was removed without realising the consequences and the wound was packed. As the conscious level declined in both, they were referred. CT brain revealed fracture in skull and changes in the brain in both. Expeditious removal of the penetrating foreign body and focal debridement of the scalp, skull, dura, and involved parenchyma and Watertight dural closure were carried out. The most important thing is not to remove the impacted foreign body at the site of accident. Craniectomy around the foreign body, debridement and removal of foreign body without zigzag motion are needed. Removal should be done following original direction of projectile injury. The neurological sequelae following the non missile penetrating head injuries are determined by the severity and location of initial injury as well as the rapidity of the exploration and fastidious debridement.

Scissors in brain: an unusual presentation of tribal culture in india

To observe the neurological complications arising from various tribal practices and their management. Penetrating head injuries comprise only a small number of total head injuries. A penetrating head injury by deliberate attempt to treat an ailment is almost unheard of. We present here a case of penetrating head injury caused by stabbing a scissor in head by a local witch doctor in order to treat a psychiatric ailment. The patient was taken up for for surgery and managed accordingly. Relevant literature was reviewed regarding various foreign bodies in traumatic missile and non missile brain injuries and their surgical management.

An unusual case of penetrating head injury in a child

Penetrating head injuries can be the result of numerous intentional or unintentional events, including missile wounds, stab wounds, and motor vehicle or occupational accidents (nails, screw-drivers). Penetrating head injuries in children constitute only a small part of the total number of traumatic head injuries seen in casualty. We report a case of neuro-trauma who was operated in our institution. Patient, 4 years male presented in casualty on 15/01/09 with a iron rod penetrating into the skull.