In conventional gunshot injuries to targets containing bone the resulting osseous fragments do not precede but follow the bullet on its further way through adjacent soft tissues. The term \"secondary projectiles\" for the particles does not appear to be appropriate since they are not believed to have enough energy necessary for creating their own wound channels away from the temporary cavity. Former studies have shown that in angled shots to glass panes the bulk of splinters does not follow the bullet\'s trajectory: The majority of the glass fragments, especially the larger ones, move at right angles to the pane shot through. The aim of the presented study was to examine whether osseous fragments behave like glass splinters in angled shots to flat synthetic bone. In this context, it should also be assessed, whether the bone fragments might act as secondary projectiles in rare cases. To answer these questions, test shots were fired to composite models consisting of flat synthetic bone and ballistic gelatin. Pistol cartridges 9 mm Luger were used to fire the shots which were video-documented with a high-speed camera. Afterwards, the composite models underwent CT examination and macroscopic inspection. Video-documentation revealed that the larger bone particles from the perforation site move at a roughly right angle from the osseous sheet into the gelatin, causing an eccentric bulge of the temporary cavity. The smaller bone fragments were also lodged along the bullet\'s path, predominantly in the cracks radiating from the permanent wound channel.

BACKGROUND: Gunshot injuries are the leading cause of death among children in the United States. The goal of this study was to better understand if certain age groups, mechanisms of injury, and type of firearms were associated with the increasing rates of pediatric gun-related trauma. We hypothesized that the extremities were disproportionately targeted when compared with the random likelihood of striking specific body-surface areas.
METHODS: This study includes pediatric firearm-related injury (FRI) patients who presented to a single free-standing level 1 pediatric hospital or died at the scene from 2010 to 2021. The hospital data was collected prospectively as part of a level 1 trauma system electronic database. Death data was collected from the local coroner\'s office.
RESULTS: Between 2010 and 2021, 1,126 pediatric FRI occurred in the geographic region studied. Demographic information available for 1,118 patients showed that 897 (80.23%) were male, and that black individuals had a statistically significant increased rate of FRI compared with white or Hispanic individuals. Mean age was 13.69 years. Most injuries were caused by handguns.
CONCLUSIONS: This data could help leaders design strategies to combat the violence, such as legislation that limits handgun access to all, especially children, and mandates safe storage of handguns. Gun-lock programs, universal background checks, and firearm-ownership education also might help stem this tide of violence.
METHODS: Level II Prognosis study.

METHODS: This study was a multicenter retrospective analysis of cervical spine gunshot wound (GSW) patients.
OBJECTIVE: The present study was conducted to evaluate the management and outcomes of vascular injuries following GSW involving the cervical spine.
BACKGROUND: Gunshot wounds (GSW) injuring the cervical spine are associated with high rates of vascular injury.
METHODS: Charts of patients with GSW involving the cervical spine at two Level 1 trauma centers were reviewed from 2010 to 2021 for demographics, injury characteristics, management and follow-up. Statistical analysis included T tests and ANOVA for comparisons of continuous variables and chi-square testing for categorical variables, non-parametric tests were used when indicated. Beta-binomial models were used to estimate the probabilities outcomes. Bayesian regression models were utilized to compute risk ratios (RR) and their 95 % confidence intervals (CI) to enhance the inferential robustness.
RESULTS: 40 patients with cervical spine GSW and associated cerebrovascular injury were included in our analysis. 15 % of patients had Biffl grade (BG) V injuries, 50 % grade IV, and 35 % grade III-I. Angiography was performed in 35 % of patients. 5 of these patients (BG V-III) required endovascular treatment for pseudoaneurysm obliteration or parent vessel sacrifice. 7 patients (22 %) showed evidence of progression. 70 % of patients were placed on antiplatelet therapy for stroke prevention. Bayesian regression models with a skeptical prior for cerebral ischemia revealed a mean RR of 4.82 (95 % CI 1.02-14.48) in the BG V group, 0.75 (95 % CI 0.13-2.26) in the BG IV group, and 0.61 (95 % CI 0.06-2.01) in the combined BG III-I group. For demise the mean RR was 3.41 (95 % CI 0.58-10.65) in the BG V group and 1.69 (95 % CI 0.29-5.97) in the BG IV group. In the high BG (V, IV) group, 54.55 % of patients treated with antiplatelet therapy had complications. None of the patients that were treated with antiplatelet therapy in the low BG (III-I) group had complications.
CONCLUSIONS: Cervical spine GSWs are associated with high-grade vascular injuries and may require early endovascular intervention. Additionally, a high rate of injury progression was seen on follow up imaging, requiring subsequent intervention. Reintervention and demise were common and observed in high BG (V, IV) groups. The incidence of stroke was low, especially in low BG (I-III) groups, suggesting that daily aspirin prophylaxis is adequate for long-term stroke prevention.

UNASSIGNED: In this study we microscopically investigated, for the first time ever, the colorimetric detectability of barium of gunshot residues (GSR) on cadaveric human skin with gunshot wounds.
UNASSIGNED: For this purpose we used two different colorimetric techniques known in the literature, namely 0.2% sodium rhodizonate (Na-R-Ba 0.2%) and sodium rhodizonate in alcoholic environment (Na-R-Ba OH 0.2%). At the same time, we have also coupled it with scanning electron microscopy with energy dispersive X-ray (SEM/EDX) analysis and the colorimetric study for the detection of lead of GSR. These techniques were applied to 16 victims who died from gunshot injuries, as well as to a control group.
UNASSIGNED: SEM/EDX demonstrated the presence of lead in all cases and barium in 11 of the 16 cases. The subsequent colorimetric technique with Na-R-Ba 0.2% did not show the barium of GSR in any case, unlike the Na-R-Ba OH 0.2% technique. This latter, in fact, has demonstrated the presence of this metal in 2 cases (18%). No microscopic case of false positive was recorded.
UNASSIGNED: The evidence obtained with Na-R-Ba OH 0.2% makes this method, applied here for the first time ever, worthy of further study. Meanwhile, although this technique can certainly be applied, it cannot be separated from the contextual colorimetric investigation for lead and the use of more sophisticated techniques.

BACKGROUND: Gunshot wounds (GSWs) to the vertebral column represent an important cause of morbidity and mortality in the United States, constituting approximately 20% of all spinal injuries. The management of these injuries is an understudied and controversial topic, given its heterogeneity and lack of follow-up data.
OBJECTIVE: To characterize the management and follow-up of GSWs to the spine.
METHODS: A multi-institutional retrospective review of the experience of two urban Level 1 trauma centers.
METHODS: Patients with GSWs to the spine between 2010-2021.
METHODS: Measures included work status, follow-up healthcare utilization, and pain management were collected.
METHODS: Charts were reviewed for demographics, injury characteristics, surgery and medical management, and follow-up. Statistical analysis included T-tests and ANOVA for comparisons of continuous variables and chi-square testing for categorical variables. All statistics were performed on SPSS v24 (IBM, Armonk, NY).
RESULTS: A total of 271 patients were included for analysis. The average age was 28 years old, 82.7% of patients were black, 90% were male, and 76.4% had Medicare/Medicaid. The thoracic spine (35%) was most commonly injured followed by lumbar (33.9%) and cervical (25.6%). Cervical GSW was associated with higher mortality (p<.001); 8.7% of patients developed subsequent osteomyelitis/discitis, 71.3% received prophylactic antibiotics, and 56.1% of cervical GSW had a confirmed vertebral or carotid artery injury. ASIA scores at presentation were most commonly A (26.9%), D (20.7%), or E (19.6%), followed by C (7.4%) and B (6.6%). 18.8% of patients were unable to be assessed at presentation. ASIA score declined in only 2 patients, while 15.5% improved over their hospital stay. Those who improved were more likely to have ASIA B injury (p<.001). Overall, 9.2% of patients underwent spinal surgery. Of these, 33% presented as ASIA A, 21% as ASIA B, 29% as ASIA C, and 13% as ASIA D. Surgery was not associated with an improvement in ASIA score.
CONCLUSIONS: Given the ubiquitous and heterogeneous experience with GSWs to the spine, rigorous attempts should be made to define this population and its clinical and surgical outcomes. Here, we present an analysis of 11 years of patients presenting to two large trauma centers to elucidate patterns in presentation, management, and follow-up. We highlight that GSWs to the cervical spine are most often seen in young black male patients. They were associated with high mortality and high rates of injury to vertebral arteries and that surgical intervention did not alter rates of discitis/osteomyelitis or propensity for neurologic recovery; moreover, there was no incidence of delayed spinal instability in the study population.

BACKGROUND: The war in Ukraine has led to a strategic reorientation of the German Armed Forces towards national and alliance defense. This has also raised the need for medical and surgical adaptation to scenarios of conventional warfare. In order to develop appropriate and effective concepts it is necessary to identify those war injuries that are associated with a relevant primary and secondary mortality and that can be influenced by medical measures (potentially survivable injuries).
OBJECTIVE: The aim of this selective literature review was to identify war injuries with high primary and secondary mortality.
METHODS: A selective literature review was performed in the PubMed® database with the search terms war OR combat AND injury AND mortality from 2001 to 2023. Studies including data of war injuries and associated mortality were included.
RESULTS: A total of 33 studies were included in the analysis. Severe traumatic brain injury and thoracoabdominal hemorrhage were the main contributors to primary mortality. Injuries to the trunk, neck, traumatic brain injury, and burns were associated with relevant secondary mortality. Among potentially survivable injuries, thoracoabdominal hemorrhage accounted for the largest proportion. Prehospital blood transfusions and short transport times significantly reduced war-associated mortality.
CONCLUSIONS: Control of thoracoabdominal hemorrhage has the highest potential to reduce mortality in modern warfare. Besides that, treatment of traumatic brain injury, burns and neck injuries has a high relevance in reducing mortality. Hospitals of the German Armed Forces need to focus on these requirements.
UNASSIGNED: HINTERGRUND: Der Krieg in der Ukraine hat zu einer strategischen Neuausrichtung der Bundeswehr auf die Landes- und Bündnisverteidigung geführt. Hieraus leitet sich auch die Notwendigkeit einer sanitätsdienstlichen und chirurgischen Anpassung auf Szenarien der konventionellen Kriegsführung ab. Um sinnvolle und wirksame Konzepte entwickeln zu können, müssen solche Kriegsverletzungen identifiziert werden, welche mit einer relevanten primären und sekundären, aber durch medizinische Maßnahmen beeinflussbaren Mortalität einhergehen („potentially survivable injuries“).
UNASSIGNED: Anhand einer selektiven Literaturrecherche sollten Kriegsverletzungen mit hoher primärer und sekundärer Mortalität herausgearbeitet werden.
METHODS: Es wurde eine selektive Literaturanalyse in PubMed® mit den Suchbegriffen „war“ OR „combat“ AND „injury“ AND „mortality“ im Zeitraum 2001 bis 2023 durchgeführt. Eingeschlossen wurden Arbeiten, die Daten zu Kriegsverletzungen und assoziierter Mortalität beinhalteten.
UNASSIGNED: Es konnten 33 Publikationen in die Analyse eingeschlossen werden. Das schwere Schädel-Hirn-Trauma sowie thorakoabdominelle Blutungen waren hauptverantwortlich für die primäre Mortalität. Verletzungen des Körperstamms, des Halses, das Schädel-Hirn-Trauma und Verbrennungen gingen mit einer relevanten sekundären Mortalität einher. Unter den „potentially survivable injuries“ machten Blutungen der Körperhöhlen den größten Anteil aus. Präklinische Bluttransfusionen und kurze Transportzeiten konnten die kriegsassoziierte Mortalität signifikant reduzieren.
CONCLUSIONS: Die Blutungskontrolle in Thorax und Abdomen besitzt aus militärchirurgischer Sicht das höchste Potenzial, um bei Kriegsverletzungen eine Reduktion der Mortalität zu erreichen. Daneben sind die Behandlung des Schädel-Hirn-Traumas, von Verbrennungen und Halsverletzungen für die Senkung der Mortalität relevant. Die Bundeswehrkrankenhäuser müssen sich diesen Anforderungen entsprechend ausrichten.

Cause of death is defined as a natural disease or injury that led to physiologic changes resulting in death. Manner of death refers to the circumstances surrounding death. Decomposition, especially in advanced stages, creates difficulties in post-mortem examination for it encompasses the processes that lead to the loss of important observable findings and features. Traumatic injuries observed in decomposed cadavers might be analyzed by their vital features and significance for the occurrence of fatal outcomes that help determine the cause and manner of death. An almost fully skeletonized cadaver was admitted to the Department of Forensic Medicine and Deontology at The Medical University, Sofia, Bulgaria. Along with the obligation to answer the post-mortem interval, what were the anthropological and biological features, the cause and manner of death had to be determined in order to classify the case as criminal or not. The cause of death was established by the morphological finding - gunshot injury of the head, passing the brain. The manner of death remained undetermined because of the absence of soft tissues in the areas of the injuries. It was concluded that there was no sufficient forensic data to answer if it was suicide, homicide, or even an accident.

OBJECTIVE: The management of femur and tibia fractures resulting from gunshot injuries is a challenge for orthopedic surgeons. One-stage and two-stage treatments are applied according to the anatomical location and severity of the injury. In this study, the importance of injury severity and anatomical location was evaluated in the choice of treatment method and its impact on prognosis in cases of lower extremity gunshot fractures.
METHODS: A total of 124 patients who met the study criteria were evaluated. They were grouped separately according to the anatomical location of the injury (femur, n = 73; tibia, n = 51) and the surgical method (one-stage, n = 77; two-stage, n = 47). The demographic characteristics of the patients, fracture classification, presence of neurological or vascular damage at the time of diagnosis, anatomical location of the injury, surgical procedure, and follow-up time were recorded. The time of union and the presence of malunion were evaluated radiologically. Finally, patients were assessed clinically with the New Injury Severity Score (NISS) and leg length discrepancy (LLD) calculated through measurements made on lower extremity orthoroentgenograms.
RESULTS: The rate of vascular injury and the number of Gustilo-Anderson type IIIB and IIIC cases were significantly higher in the two-stage treatment group (p = 0.001 and p = 0.000, respectively). The infection rate was also higher in the two-stage group; therefore, time to union was significantly longer (p = 0.004 and p = 0.05, respectively). LLD was higher among patients who received two-stage treatment (p = 0.015). According to the NISS scale used in clinical assessment, better scores were obtained for the one-stage group (p = 0.002). In comparisons made according to anatomical location, no significant difference was found between femur and tibia injuries.
CONCLUSIONS: Regardless of anatomical location and treatment method, injuries of higher severity such as Gustilo-Anderson type IIIB and IIIC are correlated with higher rates of complications such as vascular injury, postoperative infection, delayed union, and LLD. Furthermore, in cases of severe injuries, a two-stage approach is commonly favored.

Gunshot injuries and bullet removal are extremely rare indications for hip arthroscopy. We present the case of a 22-year-old male with a free-floating bullet in the hip joint after a gunshot injury. A thorough imaging investigation was used to demonstrate the exact location of the foreign body. The bullet was removed by arthroscopic means under fluoroscopic guidance. The patient has been symptom-free for two years postoperatively. The tips and tricks of the technique are discussed. Hip arthroscopy is a minimally invasive technique to remove a free-floating bullet and avoid potential long-term complications like chondral injury and lead intoxication.

Nonobstetric vaginal or vulva trauma is an extremely rare occurrence, with an incidence of < 0.2% of traumas. CT represents the gold standard in the diagnosis of gunshot lesions due to its ability to detect and stage injuries with very high sensitivity and specificity. A standardized protocol for penetrating trauma is still under debate for the use of intravenous contrast only or also rectal and oral contrast. Herein, we report a case of gunshot vaginal trauma in a 43-year-old patient presenting with vaginal bleeding. In our case, the protocol was \"patient\'s tailored,\" the intravaginal selective use of air was administered due to symptoms (vaginal bleeding) and CT findings, this 2-step protocol increased diagnostic confidence and allow a correct and challenging diagnosis.