Missile Injuries Research Articles

Intracranial penetrating injury by screw driver: A case report and review of literature

Penetrating injury to the head, with the exception of missile injuries is rare owing to thick calvarium. Orbital and temporal areas are comparatively vulnerable to penetrating injuries, due to their relative thinness. A case is presented in which a man killed his wife by forcefully thrusting a screw driver into her cranial cavity. The deceased presented to the hospital with the screw driver embedded in her head. She was declared as ‘brought dead on arrival’ at the emergency of the hospital. Pre-autopsy plain radiography and Computed Tomography (CT) of the head were done to assess the extent of brain damage. The peculiarity of this case lies in the fact that screw driver as a stabbing weapon in the head is very rarely used. In such cases, there is a need to perform radiography and CT with the weapon in-situ for better interpretation on injuries. In this paper role of radiography and CT in intra cranial penetration is discussed with review of literature.

Results of delayed repair of posterior urethral disruption injuries in Maiduguri

AimPosterior urethral disruption injuries (PUDI) are common and on the increase because of vehicular accidents and civil conflicts. The operative management of PUDI continues to pose a challenge to the urologist because of erectile dysfunction and incontinence from the injury or following repair. The aim of the present study was to review the outcome of delayed repair of PUDI.Patients and MethodsThe present study is a retrospective study of all male patients who underwent operation for PUDI at a urology unit between April 2008 and September 2010. The causes, presentation, diagnostic investigations, initial management, definitive operative management and complications were obtained from patients' clinical records.ResultsForty‐five male patients with PUDI were managed; their mean age was 37.38 ± 20.014 years (range 8–80 years). Most of the injuries were because of vehicular accidents (46.67 per cent) and missile injuries (15.56 per cent). The presenting features included inability to pass urine (100 per cent), bleeding from the urethra (60 per cent) and suprapubic swelling and pain (86.67 per cent). The initial management was a suprapubic cystostomy. Twenty‐nine (64.44 per cent) patients had associated pelvic fracture, 17 (37.78 per cent) long bone fractures and 13 (28.89 per cent) bladder injuries. Other associated injuries included the bowel, head, ribs and liver (31.12 per cent). The perineal approach in repair was effected in 37 (82.22 per cent) patients, and eight (17.78 per cent) had combined abdominal and perineal approaches. The urine flow rate was 15–20 mL/s in 36 (80 per cent) patients, and 10–15 mL/s in nine (20 per cent) patients. The main postoperative complications included wound infection, incontinence and erectile dysfunction.ConclusionPUDI are on the increase in north‐eastern Nigeria because of increases in road vehicular accidents and firearm injuries from civil strife. The main causes of PUDI in Maiduguri are road vehicular accidents, firearms and civil strife. The results of delayed repair are equally good, despite the absence of immediate endoscopic realignment.

CSI & U: Collection and Preservation of Evidence in the Emergency Department

According to Lynch,1 “Forensic nurses care for individuals whose illness, injury or death stems from acts of violence, maltreatment, abuse, neglect, or exploitation.” An ED nurse who has worked any length of time in the specialty takes care of patients who fall into this category, sometimes on a daily basis. Evidence could very well need to be collected for the following patients: those who have been in motor vehicle collisions; those who have been injured by faulty equipment or at work; those who have sustained burns, accidents, falls, electrocution, or missile injuries; those who are unidentified patients or VIPs; those who are exposed to bioterrorism or hazardous materials; those who are victims of assault or crime; those who are involved in a fire; or infants and children.

Missile Injury of the Knee Joint

SUMMARY Penetrating injuries of the knee joint are among the most difficult groups of bone - joint system injuries. They are characterized by extensive destruction of all anatomical structures of the knee joint. This paper presents two patients with penetrating wounds of the knee joint, of which one was injuried by shrapnel bomb, while another was wounded by a bullet from a gun. Both patients were treated by primary surgical treatment for penetrating wound of the joint. Arthroscopic surgery was performed in both patients to remove fragments of the bomb and bullet. Parenteral antibiotic and anti-tetanus therapy were administered in both patients. Surgical treatment of penetrating wound of the knee joint is a two-stage procedure. The first act is the primary surgical treatment of penetrating wound of the joint according to the principles of war wounds treatment. Primary surgical treatment of penetrating, gunshot wounds to the knee joint is usually from the surface to deeper layers of the wound and involves the removal of the entire non-vital, necrotic tissue. Excision of the joint capsule should be extremely sparing, but the whole damaged joint capsule must be removed. Only the joint synovial membrane can be closed primarily. If this is not possible, then the joint capsule should be closed. Other structures are left open for delayed primary closure. The second act is a delayed closure of penetrating gunshot wound of the joint. Arthroscopic removal of fragments from the knee joint is a useful method to prevent complications and infection after this injury.

Management of missile injuries to the maxillofacial region: A case series

Management of missile injuries to the maxillofacial region: A case series

Missile injuries of spine and spinal cord in civilian Kashmir – Analysis and outcome evaluated by new Modified SKIMS-Functional Scales

AimsSince the emergence of missile injuries of spinal cord is a major management-challenge due to its vulnerable vascularity, narrowly-packed neurons and tracts, associated injuries caused by kinetic-energy of missiles, we sought analysis and evaluation of missile injuries of spinal cord with the application of indigenously devised Modified SKIMS-Functional Classification, SKIMS-injury types and Modified SKIMS-Functional Outcome scale. MethodsThe study was conducted retrospectively in Neurosurgery, SKIMS, single tertiary unit in Jammu and Kashmir State of India, over a period of 22 years (January 1989–December 2010). The missile injuries of spine and spinal cord were managed under a standard medical and uniform protocol. The civilians, injured due to firing of metallic-bullets, pellets, tear-gas shells etc, received within 24 h of injury. Temporary spinal immobilization, resuscitation (ABC-Guidelines), methyl prednisolone infusion and clinico-imaging evaluation were carried out. Triaging was done by indigenous Modified SKIMS-Functional Classification and SKIMS-injury types, while results assessed by Modified SKIMS-Functional Outcome scale. ResultsAmong 334 spinal missile injuries, penetrating injuries were 55.08%, SKIMS-injury type-a (musculo-skeletal neural) 61.07% and metallic-bullets were commonest (69.76%) missiles causing 44.63% dorsal injuries. The Modified SKIMS-Functional Classification rapidly triaged and prognosticated spinal missile injuries. The CT-myelography was study of choice. The intrathecal and intramedullary missile migration, “Second-Flight of Bullet” occurred in 1.49%. About 80.83% underwent surgery. The new indigenous Trans-axillary Approach was applied in 3.33% D2-3 spinal-fixation. Meningitis and CSF leak were common. However Modified SKIMS-Functional Outcome scale showed that 47.30% (158/334) of all spinal missile injuries improved neurological grade, 14.97% (50/334) died, most of these in group A Modified SKIMS-Functional Classification, and 37.72% (126/334) patients had no improvement by the end of 6 months. Among all groups, group C was most salvageable. ConclusionThe prognosis of missile injuries of spine stays grim with only 7.18% (24/334) patients improved to Modified SKIMS-Functional Outcome group D (good-recovery). The multi-factorial criteria, not alone complete/incomplete injury-concept, ought to be framed in favour of or against surgery. The Modified SKIMS-Functional Classification, SKIMS-injury types and Modified SKIMS-Functional Outcome scale helped in rapid triaging and prognosticating the spinal missile injuries.

Timing for repair in brachial plexus injury

BackgroundBrachial plexus injuries predominantly target young individuals and result in severe functional impairment in the affected limb. Management of these injuries is challenging and functional gains are often unpredictable. Though there is a general agreement that early repairs result in better functional outcomes, a period of observation, sometimes, will allow a good spontaneous recovery in traction related injuries. Mode of injury will also have a bearing while deciding the timing of repair. MethodsIf attempted immediate, direct repair of plexal elements is feasible in clean transections. In late repairs, nerve ends retract and require nerve grafting. Missile injuries and traction induced injuries are observed for spontaneous recovery for a period of up to 3 months. Presence of pseudomeningoceles in MR myelography is an indication for an early surgery. Neurolysis, direct nerve repair, nerve grafting, nerve transfer, pedicle muscle transfer and functioning free-muscle transfer are the main surgical procedures in the management of brachial plexus injuries. ResultsGood results are expected following immediate and direct repair of clean transections in upper plexal elements. Early repairs give better results than delayed repairs in all kinds of brachial plexus lesions. ConclusionThe timing of repair in brachial plexus injury is dependent on several factors, e.g; the mechanism of injury, type of injury, speed of the vehicle, and the mode of fall while victim lands on the ground. High speed motor cycle accidents usually result in root avulsions and demand an early intervention. Clean transections should be repaired immediately, whereas missile and traction induced injuries should be observed for spontaneous recovery for a period up to 3 months.

Inferior Alveolar Nerve Injuries Associated With Mandibular Fractures

The study evaluates the incidence of inferior alveolar nerve injuries in mandibular fractures, the duration of their recovery, and the factors associated with them. Fifty-two patients with mandibular fractures involving the ramus, angle, and body regions were included in this study; the inferior alveolar nerve was examined for neurological deficit posttraumatically using sharp/blunt differentiation method, and during the follow-up period the progression of neural recovery was assessed. The incidence of neural injury of the inferior alveolar nerve was 42.3%, comminuted and displaced linear fractures were associated with higher incidence of inferior alveolar nerve injury and prolonged recovery time, and recovery of inferior alveolar nerve function occurred in 91%.Fractures of the mandible involving the ramus, angle, and body regions, and comminuted and displaced linear fractures are factors that increase the incidence of inferior alveolar nerve injuries. Missile injuries can be considered as another risk factor.

Bullet Embolization: Multidisciplinary Approach by Interventional Radiology and Surgery

Bullet embolization after penetrating trauma is an infrequent but important phenomenon. It presents an unexpected sequelae to the otherwise predictable injury pattern of penetrating missile injury mechanism and poses a challenging diagnostic and therapeutic dilemma. Bullets from penetrating wounds can gain access to the vasculature and migrate to nearly every large vascular bed. Patients can be asymptomatic, but the potential complications can be devastating including limb-threatening ischemia, sepsis, endocarditis, cardiac valvular incompetence, pulmonary embolism, stroke, and even death. The exact incidence of bullet embolization is unknown, but it was estimated to be 0.3% during the Vietnam War and 1.1% in the recent conflict in Afghanistan and Iraq. The scarcity of the condition and the lack of concentrated experience at any single institution contribute to the controversies pertaining to the management approach. Traditionally, surgical extraction of embolized bullets may involve difficult and invasive surgical exposures. Recent advancement in endovascular techniques provides an additional option in this treatment algorithm. In this article, we describe a case of venous bullet embolization from the left iliac vein treated by a combined endovascular and surgical approach.

Open versus closed reduction: mandibular condylar fractures in children

The purpose of the study was to review the literature regarding the evolution of current thoughts on management of mandibular condylar fractures (MCFs) in children. An electronic search in PubMed was undertaken in May 2012. The titles and abstracts from these results were read to identify studies within the selection criteria. Eligibility criteria included studies published in English or German from the last 20 years (from 1992 onwards) reporting clinical series of MCFs in children and adolescents until the age of 18. The search strategy initially identified 542 studies. The references from 1992 onwards totaled 339 articles. Twenty-seven studies were identified without repetition within the selection criteria. Additional hand-searching yielded two additional papers. Pediatric MCFs require thoughtful consideration in management to avoid significant growth disturbance. Early treatment is indicated in order to improve the chances for favorable development. Long-term follow-up is required, in order to properly treat late complications that may appear. Coronal computed tomography is helpful in substantiating the correct final diagnosis. Many studies show that conservative treatment (CTR) has satisfactory long-term outcome of jaw function, occlusion, and facial esthetics, despite a high frequency of radiological aberrations. Surgery before puberty should be reserved for exceptional cases such as missile injuries, in cases with extensive dislocation and lack of contact between the fragments, in cases with multiple midfacial fractures, in which the mandible has to serve as a guide to reposition the midfacial bones, and in cases which the dislocation of the fractured stump creates a functional impediment that cannot be resolved by CTR. As the craniofacial skeleton becomes more adult-like in its form at about 12 years of age, the decreased remodeling capacity in the adolescents may occasionally result in abnormally shaped condylar heads or shortened ramus heights that may lead to persistent malocclusion. Thus, the indication of open reduction and internal fixation increases with age.

Cannon-fire demonstration causing an unusual civilian missile injury

Department of Orthopaedic Surgery, University of Cincinnati, Cincinnati, OH Financial Disclosure: The authors declare no conflicts of interest. Dr. Archdeacon is a paid consultant for Stryker and has received payment for lectures from Smith & Nephew, as well as royalties for book publishing. Correspondence to Michael T. Archdeacon, MD, MSE, Department of Orthopaedic Surgery, University of Cincinnati, P.O. Box 670212, Cincinnati, OH 45267-0212 Tel: +513 558 2978; fax: +513 558 4633; e-mail. [email protected]

Nerve injuries sustained during warfare

The outcomes of 261 nerve injuries in 100 patients were graded good in 173 cases (66%), fair in 70 (26.8%) and poor in 18 (6.9%) at the final review (median 28.4 months (1.3 to 64.2)). The initial grades for the 42 sutures and graft were 11 good, 14 fair and 17 poor. After subsequent revision repairs in seven, neurolyses in 11 and free vascularised fasciocutaneous flaps in 11, the final grades were 15 good, 18 fair and nine poor. Pain was relieved in 30 of 36 patients by nerve repair, revision of repair or neurolysis, and flaps when indicated. The difference in outcome between penetrating missile wounds and those caused by explosions was not statistically significant; in the latter group the onset of recovery from focal conduction block was delayed (mean 4.7 months (2.5 to 10.2) vs 3.8 months (0.6 to 6); p = 0.0001). A total of 42patients (47 lower limbs) presented with an insensate foot. By final review (mean 27.4months (20 to 36)) plantar sensation was good in 26 limbs (55%), fair in 16 (34%) and poor in five (11%). Nine patients returned to full military duties, 18 to restricted duties, 30 to sedentary work, and 43 were discharged from military service. Effective rehabilitation must be early, integrated and vigorous. The responsible surgeons must be firmly embedded in the process, at times exerting leadership.

Secondary Missile Injury From Lightning Strike

A 48-year-old-woman was struck dead by lightning on October 24, 2010, in Pretoria, South Africa. The cause of death was due to direct lightning strike. Examination showed secondary missile injury on her legs. This secondary missile (shrapnel) injury was caused by the lightning striking the concrete pavement next to her. Small pieces of concrete were located embedded within the shrapnel wounds. This case report represents the first documented case of secondary missile formation (shrapnel injury) due to lightning strike in the literature.

Memory and anatomical change in severe non missile traumatic brain injury: ∼1 vs. ∼8years follow-up

In previous studies, we investigated a group of subjects who had suffered from a severe non missile traumatic brain injury (nmTBI) without macroscopic focal lesions and we found brain atrophy involving the hippocampus, fornix, corpus callosum, optic chiasm, and optic radiations. Memory test scores correlated mainly with fornix volumes [37,38]. In the present study, we re-examined 11 of these nmTBI subjects approximately 8 yr later. High-spatial resolution T1 weighted magnetic resonance images of the brain (1mm(3)) and standardised memory tests were performed once more in order to compare brain morphology and memory performance originally assessed 3-13 months after head injury (first study) and after 8-10 yr (present study). An overall improvement of memory test performance was demonstrated in the latest assessment, indicating that cognitive recovery in severe nmTBI subjects had not been completed within 3-13 months post-injury. It is notable that the volumes of the fornix and the hippocampus were reduced significantly from normal controls, but these volumes do not differ appreciatively between nmTBI subjects at first (after ∼1 yr) and at second (after ∼8 yr) scans. On the contrary, a clear reduction in the volume of the corpus callosus can be observed after ∼1 yr and a further significant reduction is evident after ∼8 yr, indicating that the neural degeneration in severe nmTBI continues long after the head trauma and relates to specific structures and not to the overall brain.

Fatal non-ballistic Penetrating Injury by a Metal Piece from a Rolling Machine: A Case Repor

Missile injuries are predominantly caused by firearms, shrapnels during bomb explosions, and so on. Non-ballistic penetrating missile injuries are very rare. In this case, an adult male, while working on a cold stainless steel rolling machine, had sustained a penetrating injury to the outer aspect of upper l/3rd of left thigh, by a metal piece, ejected from the metal sheet moving on the rolling machine. The metal piece entered the pelvic cavity fatally injuring his visceral organs. He was brought dead on arrival. The case is unique since it is the first reported case of a non-ballistic missile injury that was accidental and fatal. There was also no direct human involvement. In most reported cases of such kind, head injuries are the commonest, and prove to be fatal.

Penetrating orbito-cranial injury in a child

Introduction: Penetrating brain injury is a very common form of head injury all over the world. It commonly follows missile injury and impalement from assaults and fall on a sharp object. Rarely, however,self-inflicted injury from playing with a sharp object can occur. The objective of this report was to present an unusual injury from a nail that the patient was playing with. Case Report: A 7 year-old, right-handed primary two pupil presented to our center with a 2-hour history of a 6-inch nail on the head. He fell over a 6-inch nail he was holding while playing. The boy gave an account of what happened at presentation. There was no focal neurological deficit. Skull X-ray showed an orbito-cranial radio-opaque nail through the orbit. He was placed on anticonvulsant, antibiotics, and full course of tetanus prophylaxis. Neither computed tomography scan nor angiography could be done. The nail was removed successfully by craniotomy. He had an 8-week course of intravenous and oral antibiotics and had 2-year course of anticonvulsant. He has been followed up for 2 years without complications. Conclusion: Although penetrating brain injuries are common worldwide, we present the peculiar accidental injury in a child who was managed with a good outcome.

Management dilemma in penetrating head injuries in comatose patients: Scenario in underdeveloped countries

Background:The optimal management of patients with minimal injury to brain has been a matter of controversy and this is especially intensified when the patient has a poor neurological status. This is important in the regions where neurosurgical services are limited and patient turnover is disproportionate to the available resources. We aimed to determine the effectiveness of aggressive management in coma patients after penetrating missile injuries of the brain.Methods:All the patients of gunshots or blast injuries were included if they had a Glasgow Coma Scale score of less than 8 after initial resuscitation and had no other injury that could explain their poor neurological status. The indication for emergency surgery was evidence of a mass lesion causing a significant mass effect; otherwise, debridement was done in a delayed fashion. The patients who were not operated were those with irreversible shock or having small intracranial pellets with no significant scalp wounds. The patients who had a Glasgow outcome score of 1, 2, or 3 were classified as having an unfavorable outcome (UO) and those with scores 4 and 5 were classified as having a favorable outcome (FO).Results:We operated 13 patients and the rest 13 were managed conservatively. The characteristics of the patients having a favorable outcome were young age (OR = 28, P = 0 .031), normal hemodynamic status (OR = 18, P = 0.08), presence of pupillary reaction (OR = 9.7, P = 0.1), and injury restricted to one hemisphere only (OR = 15, P = 0.07). All of the patients who were in shock after resuscitation died while 25% of the patients with a normal hemodynamic status had a favorable outcome.Conclusions:In developing countries with limited resources, the patients who are in a comatose condition after sustaining penetrating missile injuries should not be managed aggressively if associated with bihemispheric damage, irreversible shock, or bilateral dilated nonreacting pupils. This is especially important in the event of receiving numerous patients with the same kind of injuries.

Missile Injury by A Weed Wacker Resulting in a False Aneurysm of the Brachial Artery

A novel now commonly used device in many countries called a “weed-wacker” is a mechanical rotating device with a cord used to trim lawns and grass. A case of a 14-year old boy with a false aneurysm of the brachial artery is presented; he sustained a missile injury by a piece of rusty steel projected by use of a weed wacker. Missile injuries by nail guns and bullets have been documented in the literature; however, this mechanism of injury by a weed-wacker has never been previously described and is presented as a unique mechanism of injury and brings attention the issue of safety with the use of the weed-wacker.

Missile War Injuries of the Face

In a society struggling to rebuild its country after 3 decades of years of dictatorships and wars, Iraqi maxillofacial and craniofacial surgeons play a critical role in treatment of many most serious terrorist missile injuries of the face by ongoing conflict in Iraq. This study reflects our surgical techniques of treating explosive missile injuries and other combat- and terrorism-related injuries and also evaluates the immediate and secondary phase managements of patients with missile injuries. This study includes 235 patients with missile war injuries of the face during a period of 4 years; all injured patients were treated in the Maxillofacial Unit of Surgical Specialties Hospital, Medical City, Baghdad. There were 195 men and 40 women; their ages ranged from 1 to 70 years (mean, 39.5 years). Posttraumatic missile facial deformities were classified as follows: 95 patients (40.43%) had bone loss; 72 patients (30.64%) had soft tissue loss; 33 patients (14.05%) had orbital injuries; and 35 patients (14.90%) had other deformities of scar contracture, fistula, and sinus formation. Two techniques were used for reconstruction of the bony defect, either by bone chips carried by osteomesh tray harvested from the iliac crest or by free block of corticocancellous bone graft from the iliac crest. Soft tissue reconstruction was done by local flaps and regional flaps such as lateral cervical and cervicofacial flaps, and the orbit was reconstructed by bone graft, lyophilized dura, and sialastic implant. Scar contracture was treated by scar revision and sinus tract excised at the same time of scar revision. In conclusion, the primary phase required an urgent airway management, controlling an active bleeding by surgical intervention; most entrance and exit wounds as well as retained missiles were located in the cheek, chin, and mandibular body, with few cases of mortality due to complications related to head injuries. The secondary phase management of deformities of the face as a complication of missile injuries was classified as bone loss, soft tissue loss, combined bone and soft tissue loss, and others (sinus tracts and poor scars).

Management of Gunshot Pelvic Fractures With Bowel Injury: Is Fracture Debridement Necessary?

Low-velocity pelvic gunshot injuries occur commonly in urban trauma centers, occasionally involving concomitant intestinal viscus injury leading to potential fracture site contamination. Surgical debridement of the fractures may be necessary to prevent osteomyelitis, although not routinely performed in many centers. The purpose of this study was to determine whether fracture debridement should be done to prevent osteomyelitis in these injuries. A 5-year retrospective review of all patients older than 12 years with low-velocity gunshot pelvic fractures was performed at an urban Level I trauma center. Medical records and radiographs/computed tomographic scans were reviewed, and data regarding fracture location, concomitant intestinal viscus injury, orthopedic surgical intervention, antibiotic treatment, and bone and/or joint infection were recorded. Of a total of 103 patients identified, 19 had expired within 48 hours and were excluded, resulting in a total of 84 study subjects for review. Fifty of 84 patients (59%) had a perforated viscus with 31 large bowel injuries and 30 small bowel injuries. Eighteen patients (21%) had intra-articular fractures, 15 of which involved the hip joint. Orthopedic surgical fracture debridement was done only in intra-articular fractures with retained bullet fragments (seven cases). Deep infection occurred in one patient with a missile injury to the hip joint with concomitant intestinal spillage. Immediate joint debridement was performed in this case, but successful missile fragment removal was not achieved until the second debridement after 48 hours. No infections occurred in any extra-articular fractures, regardless of the presence of intestinal spillage. Extra-articular gunshot pelvic fractures do not require formal orthopedic fracture debridement even in cases with concomitant intestinal viscus injury. However, debridement with bullet removal should be done in cases with intra-articular involvement, particularly if there are retained bullet fragments in the joint, to prevent deep infection.