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Gunshot Injuries: What Does a Radiologist Need to Know?¹

¹ From the Department of Radiology, Harborview Medical Center, 325 Ninth Ave, Seattle, WA 98104. From the Plenary Session, Friday Imaging Symposium: Acute Radiology—Where Minutes Count, at the 1998 RSNA scientific assembly. Received April 19, 1999; revision requested May 4 and received June 7; accepted June 9. Address reprint requests to the author.

View larger version (17K): [in a new window]   Figure 1.   Sectional diagram of a handgun bullet.

View larger version (33K): [in a new window]   Figures 2, 3.   (2) Radiograph of expended bullets. The bullets were imaged on a step sponge at various distances from the film. Thus, each has a different magnification and its caliber cannot be accurately measured. All of these bullets were fired into a water bath. Several show deformities characteristic of their construction. They are as follows: 1, soft-point 0.44 magnum bullet; 2 and 3, hollow-point 0.38 special bullet; 4 and 5, hollow-point semijacketed 9-mm bullet; 6, solid-point fully jacketed 9-mm bullet; 7, 7.62-mm fully jacketed rifle bullet; 8, jacket fragment of soft-point rifle bullet; 9, lead fragment of soft-point rifle bullet; 10, solid-point nonjacketed 0.22 bullet; and 11, hollow-point nonjacketed 0.22 bullet. (3) Bullet deformation patterns. Solid straight arrows = live rounds, open arrows = empty cartridge cases, arrowheads = spent bullets. All of the spent bullets were fired into a water bath. (The radiograph in Fig 2 includes all of the spent bullets shown here.) (a) Photograph of fully jacketed 9-mm handgun rounds shows lack of deformation of the bullet and the spiral rifling marks (curved arrow) on the sides of the bullet. (b) Photograph of hollow-point semijacketed 9-mm handgun rounds shows the characteristic mushrooming of the bullets. The bullet on the right has a metal post within its hollow nose, but this post has little effect on the overall pattern of deformity. (c) Photograph of soft-point 0.308-caliber rifle bullet shows only two of the multitude of bullet fragments from the water bath. The left fragment is a piece of lead, and the right is a piece of copper jacket.

View larger version (167K): [in a new window]   Figures 2, 3.   (2) Radiograph of expended bullets. The bullets were imaged on a step sponge at various distances from the film. Thus, each has a different magnification and its caliber cannot be accurately measured. All of these bullets were fired into a water bath. Several show deformities characteristic of their construction. They are as follows: 1, soft-point 0.44 magnum bullet; 2 and 3, hollow-point 0.38 special bullet; 4 and 5, hollow-point semijacketed 9-mm bullet; 6, solid-point fully jacketed 9-mm bullet; 7, 7.62-mm fully jacketed rifle bullet; 8, jacket fragment of soft-point rifle bullet; 9, lead fragment of soft-point rifle bullet; 10, solid-point nonjacketed 0.22 bullet; and 11, hollow-point nonjacketed 0.22 bullet. (3) Bullet deformation patterns. Solid straight arrows = live rounds, open arrows = empty cartridge cases, arrowheads = spent bullets. All of the spent bullets were fired into a water bath. (The radiograph in Fig 2 includes all of the spent bullets shown here.) (a) Photograph of fully jacketed 9-mm handgun rounds shows lack of deformation of the bullet and the spiral rifling marks (curved arrow) on the sides of the bullet. (b) Photograph of hollow-point semijacketed 9-mm handgun rounds shows the characteristic mushrooming of the bullets. The bullet on the right has a metal post within its hollow nose, but this post has little effect on the overall pattern of deformity. (c) Photograph of soft-point 0.308-caliber rifle bullet shows only two of the multitude of bullet fragments from the water bath. The left fragment is a piece of lead, and the right is a piece of copper jacket.

View larger version (168K): [in a new window]   Figures 2, 3.   (2) Radiograph of expended bullets. The bullets were imaged on a step sponge at various distances from the film. Thus, each has a different magnification and its caliber cannot be accurately measured. All of these bullets were fired into a water bath. Several show deformities characteristic of their construction. They are as follows: 1, soft-point 0.44 magnum bullet; 2 and 3, hollow-point 0.38 special bullet; 4 and 5, hollow-point semijacketed 9-mm bullet; 6, solid-point fully jacketed 9-mm bullet; 7, 7.62-mm fully jacketed rifle bullet; 8, jacket fragment of soft-point rifle bullet; 9, lead fragment of soft-point rifle bullet; 10, solid-point nonjacketed 0.22 bullet; and 11, hollow-point nonjacketed 0.22 bullet. (3) Bullet deformation patterns. Solid straight arrows = live rounds, open arrows = empty cartridge cases, arrowheads = spent bullets. All of the spent bullets were fired into a water bath. (The radiograph in Fig 2 includes all of the spent bullets shown here.) (a) Photograph of fully jacketed 9-mm handgun rounds shows lack of deformation of the bullet and the spiral rifling marks (curved arrow) on the sides of the bullet. (b) Photograph of hollow-point semijacketed 9-mm handgun rounds shows the characteristic mushrooming of the bullets. The bullet on the right has a metal post within its hollow nose, but this post has little effect on the overall pattern of deformity. (c) Photograph of soft-point 0.308-caliber rifle bullet shows only two of the multitude of bullet fragments from the water bath. The left fragment is a piece of lead, and the right is a piece of copper jacket.

View larger version (148K): [in a new window]   Figures 2, 3.   (2) Radiograph of expended bullets. The bullets were imaged on a step sponge at various distances from the film. Thus, each has a different magnification and its caliber cannot be accurately measured. All of these bullets were fired into a water bath. Several show deformities characteristic of their construction. They are as follows: 1, soft-point 0.44 magnum bullet; 2 and 3, hollow-point 0.38 special bullet; 4 and 5, hollow-point semijacketed 9-mm bullet; 6, solid-point fully jacketed 9-mm bullet; 7, 7.62-mm fully jacketed rifle bullet; 8, jacket fragment of soft-point rifle bullet; 9, lead fragment of soft-point rifle bullet; 10, solid-point nonjacketed 0.22 bullet; and 11, hollow-point nonjacketed 0.22 bullet. (3) Bullet deformation patterns. Solid straight arrows = live rounds, open arrows = empty cartridge cases, arrowheads = spent bullets. All of the spent bullets were fired into a water bath. (The radiograph in Fig 2 includes all of the spent bullets shown here.) (a) Photograph of fully jacketed 9-mm handgun rounds shows lack of deformation of the bullet and the spiral rifling marks (curved arrow) on the sides of the bullet. (b) Photograph of hollow-point semijacketed 9-mm handgun rounds shows the characteristic mushrooming of the bullets. The bullet on the right has a metal post within its hollow nose, but this post has little effect on the overall pattern of deformity. (c) Photograph of soft-point 0.308-caliber rifle bullet shows only two of the multitude of bullet fragments from the water bath. The left fragment is a piece of lead, and the right is a piece of copper jacket.

View larger version (148K): [in a new window]   Figures 4, 5.   (4) Handgun bullet injury to the head. Axial computed tomographic (CT) image of the head (bone window) shows cranial entry and exit wounds with medial beveling of the former and lateral beveling of the latter. The bullet was traveling from left to right. Note also how bone and bullet fragments from the entry wound are propelled into the brain, whereas fragments from the exit wound are propelled into the scalp. (5) Handgun bullet injury to the leg. Anteroposterior radiograph shows that the bullet traveled from lateral to medial. Most of the bone and bullet fragments are seen medial to the tibia. Note the beveling of the bone medially—toward the direction of travel.

View larger version (76K): [in a new window]   Figures 4, 5.   (4) Handgun bullet injury to the head. Axial computed tomographic (CT) image of the head (bone window) shows cranial entry and exit wounds with medial beveling of the former and lateral beveling of the latter. The bullet was traveling from left to right. Note also how bone and bullet fragments from the entry wound are propelled into the brain, whereas fragments from the exit wound are propelled into the scalp. (5) Handgun bullet injury to the leg. Anteroposterior radiograph shows that the bullet traveled from lateral to medial. Most of the bone and bullet fragments are seen medial to the tibia. Note the beveling of the bone medially—toward the direction of travel.

View larger version (127K): [in a new window]   Figure 6a.   Gunshot injury to the neck. (a) Lateral radiograph of the neck shows a fracture of the mandible with adjacent bullet fragments (arrow) and a single large bullet fragment in front of the cervical spine. (b, c) Axial CT images obtained through the mandible (b) and just below the mandible (c) show that these are two separate injuries. The distribution of bone and bullet fragments (arrows in b) shows that the bullet that caused the mandibular fracture traveled from left to right. Vertebral fractures and lead in the spinal canal (straight arrow in c) indicate that the bullet (curved arrow in c) traveled through the spinal canal and vertebral body. The patient was intubated and pharmaceutically paralyzed when he arrived in the emergency department, and his quadriplegia was not suspected until these images were obtained.

View larger version (111K): [in a new window]   Figure 6b.   Gunshot injury to the neck. (a) Lateral radiograph of the neck shows a fracture of the mandible with adjacent bullet fragments (arrow) and a single large bullet fragment in front of the cervical spine. (b, c) Axial CT images obtained through the mandible (b) and just below the mandible (c) show that these are two separate injuries. The distribution of bone and bullet fragments (arrows in b) shows that the bullet that caused the mandibular fracture traveled from left to right. Vertebral fractures and lead in the spinal canal (straight arrow in c) indicate that the bullet (curved arrow in c) traveled through the spinal canal and vertebral body. The patient was intubated and pharmaceutically paralyzed when he arrived in the emergency department, and his quadriplegia was not suspected until these images were obtained.

View larger version (129K): [in a new window]   Figure 6c.   Gunshot injury to the neck. (a) Lateral radiograph of the neck shows a fracture of the mandible with adjacent bullet fragments (arrow) and a single large bullet fragment in front of the cervical spine. (b, c) Axial CT images obtained through the mandible (b) and just below the mandible (c) show that these are two separate injuries. The distribution of bone and bullet fragments (arrows in b) shows that the bullet that caused the mandibular fracture traveled from left to right. Vertebral fractures and lead in the spinal canal (straight arrow in c) indicate that the bullet (curved arrow in c) traveled through the spinal canal and vertebral body. The patient was intubated and pharmaceutically paralyzed when he arrived in the emergency department, and his quadriplegia was not suspected until these images were obtained.

View larger version (153K): [in a new window]   Figure 7a.   High-velocity rifle injury to the hip. Anteroposterior (a) and lateral (b) radiographs of the left hip show the typical lead snowstorm appearance of a high-velocity soft-point rifle bullet. The bullet was traveling from front to back. On the anteroposterior view (a), the lead fragments are distributed in a circular pattern. On the lateral view (b), the fragments show a conical distribution, with the apex of the cone at the femoral fracture site and the base of the cone posterior. This distribution of lead confirms the direction of travel. The severe comminution of the fracture from this high-energy injury makes it difficult to use beveling of the bone to help determine the direction of travel.

View larger version (135K): [in a new window]   Figure 7b.   High-velocity rifle injury to the hip. Anteroposterior (a) and lateral (b) radiographs of the left hip show the typical lead snowstorm appearance of a high-velocity soft-point rifle bullet. The bullet was traveling from front to back. On the anteroposterior view (a), the lead fragments are distributed in a circular pattern. On the lateral view (b), the fragments show a conical distribution, with the apex of the cone at the femoral fracture site and the base of the cone posterior. This distribution of lead confirms the direction of travel. The severe comminution of the fracture from this high-energy injury makes it difficult to use beveling of the bone to help determine the direction of travel.

View larger version (75K): [in a new window]   Figure 8a.   Low-velocity bullet injury to the thigh. Anteroposterior (a) and lateral (b) radiographs of the thigh show a bullet (curved arrow) that is intact and remote from the entry wound (straight arrow). The bullet entered the skin at a steep angle and did not penetrate the fascia. Instead, it traveled distally through the subcutaneous fat until it ran out of energy adjacent to the patella and stopped. Note that the bullet tumbled 180° as it traveled, and its distal end now points toward the entry wound. (Reprinted, with permission, from reference 13.)

View larger version (83K): [in a new window]   Figure 8b.   Low-velocity bullet injury to the thigh. Anteroposterior (a) and lateral (b) radiographs of the thigh show a bullet (curved arrow) that is intact and remote from the entry wound (straight arrow). The bullet entered the skin at a steep angle and did not penetrate the fascia. Instead, it traveled distally through the subcutaneous fat until it ran out of energy adjacent to the patella and stopped. Note that the bullet tumbled 180° as it traveled, and its distal end now points toward the entry wound. (Reprinted, with permission, from reference 13.)

View larger version (31K): [in a new window]   Figures 9, 10.   (9) Sectional diagram of a shotgun cartridge. The shotgun shell is encased in a plastic cylinder with a brass cap at its base. The distal end of the cartridge contains the pellets (shot), which are separated from the charge by plastic or paper wadding. As with bullet cartridges, the firing pin of the gun detonates the primer, which in turn ignites the charge. The expanding gases from the burning charge expel the pellets from the cartridge and along the barrel of the gun. (10) Shotgun pellets. Photograph shows four groups of pellets. The left three groups are different sizes of birdshot. The right group is size 00 buckshot. The pellets in this photograph are all made of lead.

View larger version (79K): [in a new window]   Figures 9, 10.   (9) Sectional diagram of a shotgun cartridge. The shotgun shell is encased in a plastic cylinder with a brass cap at its base. The distal end of the cartridge contains the pellets (shot), which are separated from the charge by plastic or paper wadding. As with bullet cartridges, the firing pin of the gun detonates the primer, which in turn ignites the charge. The expanding gases from the burning charge expel the pellets from the cartridge and along the barrel of the gun. (10) Shotgun pellets. Photograph shows four groups of pellets. The left three groups are different sizes of birdshot. The right group is size 00 buckshot. The pellets in this photograph are all made of lead.

View larger version (120K): [in a new window]   Figure 11.   Shotgun injury to the head. Anteroposterior radiograph of a self-inflicted injury from a 12-gauge shotgun shows the devastating injury that a contact wound from a shotgun can produce.

View larger version (138K): [in a new window]   Figure 12a.   Shotgun injury to the shoulder. (a) Anteroposterior radiograph of the shoulder shows a tight pattern of birdshot. Some of the pellets are no longer round, and there are tiny scattered pieces of metal. This deformity and fragmentation confirm that the pellets are made of lead. Because the region of injury included the axillary vessels, angiography was performed. (b) Angiogram shows intravascular pellets (arrows).

View larger version (130K): [in a new window]   Figure 12b.   Shotgun injury to the shoulder. (a) Anteroposterior radiograph of the shoulder shows a tight pattern of birdshot. Some of the pellets are no longer round, and there are tiny scattered pieces of metal. This deformity and fragmentation confirm that the pellets are made of lead. Because the region of injury included the axillary vessels, angiography was performed. (b) Angiogram shows intravascular pellets (arrows).

View larger version (170K): [in a new window]   Figure 13a.   Pellet embolization to the lungs. (a) Anteroposterior radiograph of the chest shows two well-separated shotgun pellets projected over the right lung (arrows). (b) Lateral radiograph shows that at least one of the pellets is centrally located within the chest (arrow). These pellets were emboli from a close-range injury to the lower back with injury to the inferior vena cava. (Reprinted, with permission, from reference 13.)

View larger version (169K): [in a new window]   Figure 13b.   Pellet embolization to the lungs. (a) Anteroposterior radiograph of the chest shows two well-separated shotgun pellets projected over the right lung (arrows). (b) Lateral radiograph shows that at least one of the pellets is centrally located within the chest (arrow). These pellets were emboli from a close-range injury to the lower back with injury to the inferior vena cava. (Reprinted, with permission, from reference 13.)

View larger version (108K): [in a new window]   Figure 14a.   Gunshot injury to the foot. Anteroposterior (a) and lateral (b) radiographs of the foot show a fully jacketed 9-mm bullet in the soft tissues of the sole of the foot with a comminuted third metatarsal fracture superior and posterior to the bullet. The relationship of the bullet and the fracture indicate that the projectile came from above and behind, confirming that this patient literally "shot himself in the foot."

View larger version (87K): [in a new window]   Figure 14b.   Gunshot injury to the foot. Anteroposterior (a) and lateral (b) radiographs of the foot show a fully jacketed 9-mm bullet in the soft tissues of the sole of the foot with a comminuted third metatarsal fracture superior and posterior to the bullet. The relationship of the bullet and the fracture indicate that the projectile came from above and behind, confirming that this patient literally "shot himself in the foot."

View larger version (149K): [in a new window]   Figure 15a.   Gunshot injury to the face. Anteroposterior (a) and lateral (b) radiographs of the face show a mandibular fracture with scattered bone and bullet fragments posterior to the mandible. This appearance confirms that the assailant was standing in front of the victim and did not shoot from behind, as the victim (who was also armed) had claimed.

View larger version (153K): [in a new window]   Figure 15b.   Gunshot injury to the face. Anteroposterior (a) and lateral (b) radiographs of the face show a mandibular fracture with scattered bone and bullet fragments posterior to the mandible. This appearance confirms that the assailant was standing in front of the victim and did not shoot from behind, as the victim (who was also armed) had claimed.

View larger version (146K): [in a new window]   Figure 16a.   Gunshot injury in a young man who presented to the emergency department with a single bullet hole in the posterior thorax. (a, b) Anteroposterior (a) and lateral (b) chest radiographs show at least three separate clumps of lead (arrow and arrowheads), which could not possibly have come from a single bullet. (c) An old anteroposterior radiograph from the files shows that two of the clumps of lead predated the current injury. The rather superficial complete bullet (arrow in a and b) is not present on the old radiograph and was the only acute injury.

View larger version (148K): [in a new window]   Figure 16b.   Gunshot injury in a young man who presented to the emergency department with a single bullet hole in the posterior thorax. (a, b) Anteroposterior (a) and lateral (b) chest radiographs show at least three separate clumps of lead (arrow and arrowheads), which could not possibly have come from a single bullet. (c) An old anteroposterior radiograph from the files shows that two of the clumps of lead predated the current injury. The rather superficial complete bullet (arrow in a and b) is not present on the old radiograph and was the only acute injury.

View larger version (140K): [in a new window]   Figure 16c.   Gunshot injury in a young man who presented to the emergency department with a single bullet hole in the posterior thorax. (a, b) Anteroposterior (a) and lateral (b) chest radiographs show at least three separate clumps of lead (arrow and arrowheads), which could not possibly have come from a single bullet. (c) An old anteroposterior radiograph from the files shows that two of the clumps of lead predated the current injury. The rather superficial complete bullet (arrow in a and b) is not present on the old radiograph and was the only acute injury.