Gunshot Wound

A 5-year-old girl was brought to the emergency department after she was injured during a drive-by shooting. She had 5 small entry wounds: 2 in the arm, 2 in the buttocks, and 1 in the left torso. Radiographs confirmed that a piece of pellet had entered her upper torso but was not in the lung or causing any problem.

The wounds were cleaned, and the patient was treated with pain medicine and oral clindamycin, because of the increased risk of infection with methicillin-resistant Staphylococcus aureus in her community. There was no sign of infection or major injury at her initial visit and at 1-week follow-up. The surgeons who evaluated her decided to leave all the embedded fragments in place. 

The patient’s injuries were caused by handgun ammunition called "snakeshot," which is typically used to shoot small varmints or snakes. This ammunition is similar to shotgun pellets; a plastic cap full of tiny pellets comes off the bullet when it is fired, and the pellets spread out. Along with this 5-year-old girl, 7 other people were wounded during the shooting.

Penetrating gunshot wounds or embedded ballistic fragments generally do not require removal and rarely cause problems when embedded in soft tissue.¹ Whether patients with embedded fragments can undergo an MRI if needed in the future is an important question to consider.

Several factors should be taken into account²:

• The composition of the fragment, if known (lead or steel), sometimes referred to as its ferromagnetism.
• The fragment’s proximity to a large blood vessel or blood vessel that is vital to a major organ.
• The fragment’s proximity to a major organ.

Most pellet guns have lead-based pellets; however, other metals are often mixed in that are magnetic.³ The metal in the fragment can create "noise" on the MRI scan and blur the findings. MRI is not done if the fragment could be dislodged into a blood vessel or cause problems in a major organ. However, once embedded, the fragments are unlikely to move. When there is doubt about the metal or location of the fragment, ultrasonography and CT would be considered better modalities.

The mother and child were offered trauma counseling in the hospital but declined. At the 1-week follow-up, the mother reported that her daughter was having nightmares and nocturnal enuresis and was nervous about going outside. She was referred by our social worker for psychological counseling for concerns of post-traumatic stress.

References:

REFERENCES:

1.

Eylon S, Mosheiff R, Libergall M, et al. Delayed reaction to shrapnel retained in soft tissue.

Injury

. 2005;36:275-281.

2.

Teitelbaum GP, Yee CA, Van Horn DD, et al. Metallic ballistic fragments: MR imaging safety and artifacts.

Radiology.

1990;175:855-859.

3.

Oliver C, Kabala J. Air gun pellet injuries: the safety of MR imaging.

Clin Radiol

. 1997;52:299-300.