Wound Ballistics and Tissue Damage

Abstract

With globally increasing war, conflicts and terrorism acts, blast or bullet limb injuries are seen more often and present a surgical challenge.The amount of tissue damage and the injury severity of gunshot injuries are due to the energy transmitted by the bullets or projectiles, depending mainly on their velocity. Therefore, the injuries are not divided any more, as in the past, to "high-and low-velocity injury" but to "a high-or low-energy injury."Blast injuries are also energy related and mainly dependent upon the distance from the blast, the energy released from the bombing device, the media (air or water) and the environment in which the blast takes place (close or open). Although the injury may look superficial, it might be much worse and the external wound is sometimes only the tip of the iceberg. Bullet and Projectile BallisticsProjectile or bullet injuries may be classified as "lowenergy" or "high-energy," which describe the amount of damage to the tissues. The factor that most affects the injury severity is the amount and the efficiency of energy transfer [1][2][3][4][5], which is mostly related to kinetic energy that is presented by the equation2 ] (M -mass; V -velocity)" in a bullet that does not "waste" energy on deforming. Other suggested theories are the momentum theory expressed as "Mass × Velocity" and the power theory related to "Mass × Velocity 3 " [6]. Ballistic wounds can be classified, according to the amount of energy causing them, into: high energy (>1,000 J); medium energy (250-1,000 J); low energy (<250 J) [7]. For example, this is the basic principle of successful open fracture classification system as described by GustiloAnderson [8,9].The energy importance is represented by most shot wound classifications, such as the Red Cross classification for war injury [10] that emphasizes wound severity in terms of tissue damage and injuries to specific anatomic structures. The injury is rated according to the size of the entry and exit wounds. It also categorizes the presence of a cavity, a fracture, or an injured vital structure and the presence or absence of metallic bodies [10]. The modified Red Cross classification for civilian injuries, [11] which incorporates the ballistic and clinical aspects of gunshot injuries in civilians, is based on energy dissipation, vital structures injured, type of wound created, severity of bony injury, degree of contamination, and the modified Gustilo-Anderson open fracture classification system in which lowvelocity gunshot wounds are designated as Grade I or Grade II, based on the size of the skin wound and highvelocity gunshot injuries are designated as Grade III injuries, regardless of wound size [12].The cascade of a shot starts with pulling the trigger. This leads to the quick expansion of gas that may reach a temperature of over 2,800°C. This produces

Staged Surgical Management of Open Navicular Fracture Secondary to a Gunshot Injury

“…Interestingly, it should be noted that there has been a recent shift in the open fracture literature advocating primary closure of these injuries when appropriate (25). However, the authors believe that a delayed approach helps the soft tissue heal prior to incision placement to minimize wound healing concerns as there is a concern for further necrosis in accord with blast effect after the initial surgical debridement, no matter how thoroughly the soft tissue injury is debrided (26). The authors advocate a systematic staged approach to GSW injuries to the foot using antibiotics, provisional fixation to allow soft tissue healing, and then final definitive fixation with arthrodesis to the affected joint(s).…”

Distal Lower Extremity Revascularization for Limb Salvage After Close Shotgun Injuries

“…14 The cases in the present study were not subjected to low velocity civilian "gunshot" injuries, but they were the victims of "shotguns" which also have relatively low velocity but the damage induced to the affected part of the body is relatively high. 15 From the point of "wound ballistics", wounds are classified according to the amount of energy induced to the wound as follows; high energy (>1,000 J), medium energy (250-1,000 J), and low energy (<250 J). 16 This classification forms the basis of the classification provided by Gustilo-Anderson.…”

“…18 The shotgun pellets have distinct features based on their higher powder charge and stuffing, the damage they cause further increases. 15,19…”

Management of ballistic soft tissue injuries: a review

“…Bullet or projectile injuries have been usefully classified into "high-energy" or "low-energy" injuries reflecting the degree of tissue damage. The amount of energy transferred at impact with the tissues is influenced by the nature of the tissues; more rigid tissues offer a greater resistance and result in higher energy transfers and hence sustain greater damage, for instance, bone would be more readily injured than a more pliable tissue [9]. The zones of injury have been classified into three zones and this is a useful way of conceptualising tissue damage.…”