Gunshot Wounds: Ballistics, Pathology, and Treatment Recommendations, with a Focus on Retained Bullets

Abstract As the epidemic of gunshot injuries and firearm fatalities continues to proliferate in the United States, knowledge regarding gunshot wound (GSW) injury and management is increasingly relevant to health-care providers. Unfortunately, existing guidelines are largely outdated, written in a time that high-velocity weapons and deforming bullets were chiefly restricted to military use. Advances in firearm technology and increased accessibility of military grade firearms to civilians has exacerbated the nature of domestic GSW injury and complicated clinical decision-making, as these weapons are associated with increased tissue damage and often result in retained bullets. Currently, there is a lack of literature addressing recent advances in the field of projectile-related trauma, specifically injuries with retained bullets. This review aims to aggregate the available yet dispersed findings regarding ballistics, GSW etiology, and treatment, particularly for cases involving retained projectiles.

• Publication year

  2022

• Venue

  Orthopedic Research and Reviews

• Publication date

  2022-09-01

• Fields of study

  Medicine

• Identifiers
  DOI 10.2147/ORR.S378278PMID 36090309PMCID 9462949
• External record

  Open on Semantic Scholar

• Source metadata

  Semantic Scholar, PubMed

• No claims are published for this paper.

• No concepts are published for this paper.

• Gunshot Injuries of the Hand: Incidence, Treatment Characteristics, and Factors Associated With Healthcare Utilization

  2021cited by this paper
• The impact of retained bullet fragments on outcomes in patients with gunshot wounds.

  2021cited by this paper
• Evidence-Based Approach to Timing of Nerve Surgery

  2021cited by this paper
• Lead poisoning induced by gunshot injury with retained bullet fragments.

  2021cited by this paper
• Retained Bullet Fragments after Non-Fatal Gunshot Wounds: Epidemiology and Outcomes.

  2021cited by this paper
• Firearms-related skeletal muscle trauma: pathophysiology and novel approaches for regeneration

  2021cited by this paper
• Surgical removal of a migrating intraspinal bullet: illustrative case

  2021cited by this paper
• Acute Arthroscopic Removal of a Bullet Embedded in the Glenoid: A Case Report

  2021cited by this paper
• Management of gunshot wound-related hip injuries: A systematic review of the current literature.

  2021cited by this paper
• Management of Civilian Low-Velocity Gunshot Injuries to an Extremity.

  2021influential reference
• Epidemiologic Trends in Fatal and Nonfatal Firearm Injuries in the US, 2009-2017.

  2020cited by this paper
• Retained bullet in the cervical spinal canal and the associated surgical management conundrum: case report and review of the literature

  2020cited by this paper
• Lead Toxicity From Intradiscal Retained Bullet Fragment: Management Considerations and Recommendations.

  2020cited by this paper
• Surgical Treatment of Upper Extremity Gunshot Injures: An Updated Review.

  2020cited by this paper
• The role of arthroscopy in bullet removal: A systematic review of the literature.

  2020cited by this paper
• Treatment of secondary hip arthritis from shell fragment and gunshot injury in the Syrian civil war

  2020cited by this paper
• Retained Bullets After Firearm Injury: A Survey on Surgeon Practice Patterns

  2020cited by this paper
• Operative Versus Nonoperative Management Of Traumatic Arthrotomies from Civilian Gunshot Wounds.

  2019influential reference
• Are Patients With Retained Bullet Fragments at Greater Risk for Elevated Blood Lead Levels?

  2019cited by this paper
• A systematic approach to the interpretation of gunshot wound trauma to the cranium.

  2019cited by this paper
• Retained Shrapnel from a Blast Injury as a Rare Cause of Secondary Osteoarthritis of the Hip Joint: A Case Report and Review of Literature

  2019cited by this paper
• Lead Toxicity from Retained Bullet Fragments: A Systematic Review and Meta-Analysis.

  2019cited by this paper
• Arthroscopic Treatment of a Low-Velocity Gunshot Injury to a Primary Total Hip Arthroplasty: A Case Report

  2019cited by this paper
• Arthroscopic bullet removal from the hip joint and concurrent treatment of associated full-thickness chondral defects: A case report

  2019cited by this paper
• Gunshot Wounds to the Upper Extremity.

  2019influential reference
• Gunshot Wounds: Ballistics and Imaging Findings.

  2019influential reference
• Extra-Articular Retained Missiles; Is Surveillance of Lead Levels Needed?

  2018influential reference
• Spinal Gunshot Wounds: Pattern and Associated Lesions in Civilians

  2018influential reference
• Lead Toxicity from a Retained Bullet.

  2018cited by this paper
• Arthroscopic removal of an intraarticular bullet from the hip joint: A case report.

  2018cited by this paper
• The management of low velocity transarticular gunshot injuries: A pilot study

  2018cited by this paper
• Variation in treatment of low energy gunshot injuries - A survey of OTA members.

  2018influential reference
• Infection Rates and Treatment of Low-Velocity Extremity Gunshot Injuries

  2017influential reference
• A systematic review on ricochet gunshot injuries.

  2017cited by this paper
• Bullet Fragment–Induced Lead Arthropathy with Subsequent Fracture and Elevated Blood Lead Levels

  2017cited by this paper
• Lead Poisoning in Children and Adults

  2017cited by this paper
• Migratory low velocity intradural lumbosacral spinal bullet causing cauda equina syndrome: report of a case and review of literature

  2017influential reference
• Ankle Lead Arthropathy and Systemic Lead Toxicity Secondary to a Gunshot Wound After 49 Years: A Case Report.

  2017cited by this paper
• Severe lead toxicity attributed to bullet fragments retained in soft tissue

  2017cited by this paper
• Infection and Complications After Low-velocity Intra-articular Gunshot Injuries

  2017influential reference
• Wound ballistics 101: the mechanisms of soft tissue wounding by bullets

  2017influential reference
• The influence of the bullet shape on the width of abrasion collars and the size of gunshot entrance holes

  2017influential reference
• Arthroscopic Removal of Shotgun Pellet From Within the Medial Meniscus.

  2016cited by this paper
• Gunshot wounds: A review of ballistics, bullets, weapons, and myths.

  2016cited by this paper
• Surgeon preferences regarding antibiotic prophylaxis for ballistic fractures

  2016cited by this paper
• Treatment of the Bullet, Traversing Femoral Neck, Lodged in Hip Joint: Initial Arthroscopic Removal and Subsequent Cartilage Repair

  2016influential reference
• Compartment Syndrome Following Arthroscopic Removal of a Bullet in the Knee Joint after a Low-Velocity Gunshot Injury

  2016cited by this paper
• Surgical hip dislocation for removal of retained intra-articular bullets.

  2016cited by this paper
• Comparative Evaluation of Potentially Radiolucent Projectile Components by Radiographs and Computed Tomography

  2016cited by this paper
• Retained Lumbar Bullet: A Case Report of Chronic Lead Toxicity and Review of the Literature.

  2016cited by this paper
• Arthroscopic Bullet Removal From the Central and Peripheral Compartments of the Hip Joint.

  2016cited by this paper
• Gunshot-induced fractures of the extremities: a review of antibiotic and debridement practices

  2015influential reference
• Firearms, bullets, and wound ballistics: an imaging primer.

  2015cited by this paper
• High velocity gunshot injuries to the extremities: management on and off the battlefield

  2015cited by this paper
• Bullet Fragment of the Lumbar Spine: The Decision Is More Important Than the Incision

  2015cited by this paper
• A Bullet in the Supraspinatus Compartment Successfully Removed by Arthroscopy: Case Report and Review of the Literature

  2015cited by this paper
• Lead Toxicity Risks in Gunshot Victims

  2015cited by this paper
• Myths and Misinformation About Gunshot Wounds may Adversely Affect Proper Treatment

  2015cited by this paper
• Gunshot injuries of the spine.

  2015cited by this paper
• Image-guided scapulothoracic arthroscopy for removing firearm projectiles

  2014cited by this paper
• Prevention of Infection in the Treatment of One Thousand and Twenty-Five Open Fractures of Long Bones. Retrospective and Prospective Analyses

  2014cited by this paper
• Wounds of war in the civilian sector: principles of treatment and pitfalls to avoid

  2014influential reference
• Cervical spine injury from gunshot wounds.

  2014cited by this paper
• Spontaneous migration of bullet from arm to forearm and its ultrasound guided removal

  2013cited by this paper
• The Effect of Intermediate Clothing Targets on Shotgun Ballistics

  2013cited by this paper
• Surgical management principles of gunshot-related fractures.

  2013influential reference
• Retained Bullet Removal in Civilian Pelvis and Extremity Gunshot Injuries: A Systematic Review

  2013cited by this paper
• Determining the wounding effects of ballistic projectiles to inform future injury models: a systematic review

  2013cited by this paper
• Antibiotics in the Treatment of Low-velocity Gunshot-induced Fractures: A Systematic Literature Review

  2013cited by this paper
• Remote ballistic fractures in a gelatine model - aetiology and surgical implications

  2013cited by this paper
• Transabdominal Gunshot Wounds of the Hip and Pelvis

  2013cited by this paper
• Management of gunshot wounds to the hand: a literature review.

  2013cited by this paper
• Causes of spinal cord injury.

  2013cited by this paper
• Bullet in hip joint.

  2013cited by this paper
• Forensic and clinical issues in the use of frangible projectile.

  2013cited by this paper
• The Long-term Outcome of Retained Foreign Bodies in Pediatric Gunshot Wounds

  2012cited by this paper
• Experimental study of the expansion dynamic of 9 mm Parabellum hollow point projectiles in ballistic gelatin.

  2012cited by this paper
• Indications for bullet removal: overview of the literature, and clinical practice guidelines for European trauma surgeons

  2012cited by this paper
• Arthroscopic Bullet Removal from the Acetabulum (Hip Joint)

  2012cited by this paper
• Ballistic injuries in the emergency department.

  2011influential reference
• Utilization of the Safe Surgical Dislocation Approach of the Hip to Retrieve a Bullet from the Femoral Head

  2011cited by this paper
• Case report: lead toxicity associated with an extra-articular retained missile 14 years after injury.

  2011cited by this paper
• The Role of Débridement in Low-Velocity Civilian Gunshot Injuries Resulting in Pelvis Fractures: A Retrospective Review of Acute Infection and Inpatient Mortality

  2011cited by this paper
• A civilian perspective on ballistic trauma and gunshot injuries

  2010cited by this paper
• Arthroscopic bullet extraction from the hip in the lateral decubitus position

  2010cited by this paper
• Civilian Gunshot Wounds of the Hip and Pelvis

  2010cited by this paper
• Arthroscopic bullet extraction from the hip in the lateral decubitus position.

  2010cited by this paper
• Lead toxicity associated with a gunshot-induced femoral fracture. A case report.

  2009cited by this paper
• Anatomic location of penetrating lower-extremity trauma predicts compartment syndrome development.

  2009cited by this paper
• Treating civilian gunshot wounds to the extremities in a level 1 trauma center: our experience and recommendations.

  2009cited by this paper
• Historical overview of wound ballistics research

  2009influential reference
• Late arthroscopic retrieval of a bullet from hip joint

  2009cited by this paper
• Wound ballistics: Minié ball vs. full metal jacketed bullets--a comparison of Civil War and Spanish-American War firearms.

  2009cited by this paper
• Joint and long-bone gunshot injuries.

  2009cited by this paper
• Forensic imaging of projectiles using cone-beam computed tomography.

  2009cited by this paper
• Versorgungsstrategien bei Schussverletzungen der Extremität

  2008cited by this paper
• Gunshot wounds to the spine: literature review and report on a migratory intrathecal bullet.

  2008cited by this paper
• Prevention and management of infections associated with combat-related extremity injuries.

  2008cited by this paper
• [Treatment strategies for gunshot wounds of the extremities].

  2008influential reference
• Arthroscopically assisted minimally invasive intraarticular bullet extraction: technique, indications, and results.

  2008cited by this paper

• An experimental study of bullet mass and velocity and their relation to fracture patterns in flat bones

  2026cites this paper
• Management Protocol for Ballistic and Other High-Energy Avulsive Facial Injuries—An Update for the 21st Century

  2026cites this paper
• Magnetic Resonance Imaging of Patients With Retained Ballistic Projectiles: A Review of Ferromagnetism, Ammunition Composition, and Safety Protocols

  2026cites this paper
• Incidental Finding of a Retained Foreign Body Following Unintentional Gunshot Injury

  2025influential citation
• A Medical Miracle: Surviving a Perforating Gunshot Injury to the Neck

  2025cites this paper
• Interosseous impasse: a unique case of bullet lodgement between the radius and ulna

  2025cites this paper
• Gravitational Effects of a Small Primordial Black Hole Passing Through the Human Body

  2025cites this paper
• Introduction to Ballistic Injuries

  2025cites this paper
• Presentation and Management of Self-Inflicted Gunshot Wounds to the Face

  2025cites this paper
• Total Hip Arthroplasty After Gunshot-Related Hip Injuries: Case Series and Review of Literature

  2025cites this paper
• Diagnosis and Management of Pediatric Ballistic Fractures.

  2025cites this paper
• Mechanism matters for major vascular injury in children: A TQIP analysis.

  2025cites this paper
• Trauma, firearms, and pregnancy: Beyond the cushion

  2025cites this paper
• Hand and Digital Ballistic Injuries.

  2025cites this paper
• Cranial gunshot wounds: comparative analysis of management and outcomes in a United Kingdom Major Trauma Centre and the United States.

  2025cites this paper
• Current Evidence in the Management of Ballistic Peripheral Nerve Injuries.

  2025cites this paper
• Demographics, Complications, and Management of Genitourinary Gunshot Wounds: National Trauma Data Bank Analysis.

  2025cites this paper
• Physicochemical characterization of lead-resistant soil bacteria from Maimalari Military Cantonment, Maiduguri

  2025cites this paper
• Autoelimination of Retained Bullet

  2025cites this paper
• Clasificación morfológica de heridas por proyectil de arma de fuego en columna vertebral

  2025cites this paper
• Firearm injuries in pediatric surgery: Pediatric trauma center experiences

  2025influential citation
• Chitosan@DOTAGA-based hydrogel: A metal-chelating dressing for the treatment of complex wounds.

  2025cites this paper
• Advancing Diagnostic Tools in Forensic Science: The Role of Artificial Intelligence in Gunshot Wound Investigation—A Systematic Review

  2025cites this paper
• Sequelae and Care After Firearm Injury.

  2025cites this paper
• From Description to Diagnostics: Assessing AI’s Capabilities in Forensic Gunshot Wound Classification

  2025cites this paper
• The Motown Corkscrew: A Simple Method for Extraction of an Embedded Intra-Articular Foreign Body.

  2025cites this paper
• Gunshot Wounds in the Lower Extremities: Treatment Review

  2025cites this paper
• Features of Diagnosis and Surgical Treatment of Fragment Embolism of the Right Ventricle in Mine-Blast Injuries

  2025cites this paper
• Surgical Considerations and Neurological Outcomes in Ballistic Penetrating Subaxial Cervical Spine Fractures: A Retrospective Analysis.

  2025cites this paper
• Healthcare utilisation among low-income individuals affected by violence in Rio de Janeiro, Brazil: a retrospective cohort study

  2025cites this paper
• Acute management of low energy civilian gunshot wounds.

  2025cites this paper
• Variation in treatment of long bone gunshot wound fractures across South Africa.

  2025cites this paper
• Firearm Injuries: A Review of Wound Ballistics and Related Emergency Management Considerations

  2025influential citation
• Infection Epidemiology, Antibiotic Treatment, and Microorganism Profiles in Urban Civilian Low Energy Firearm Fractures

  2025cites this paper
• The Minimally Invasive Posterior Approach: A Novel Technique for Shrapnel Removal in the Knee

  2025cites this paper
• Partial patellectomy and revision TKA for open periprosthetic patellar fracture from intra-articular missile: a case report

  2025cites this paper
• FEATURES OF SURGICAL TREATMENT OF COMBINED GUNSHOT WOUNDS OF THE HIP JOINT

  2025cites this paper
• DESTRUCTION OF BONE AND SURROUNDING TISSUES IN CASE OF GUNSHOT FRACTURES OF LONG BONES OF THE EXTREMITIES (CLINICAL AND RADIOLOGICAL CLASSIFICATION). FIRST REPORT

  2025cites this paper
• A Decade-Long Delay in Presentation of Retained Foreign Bodies as Sequelae of Ballistic Injuries: A Report of Two Cases

  2025cites this paper
• Low-Velocity Ballistic Trauma-Related Upper Extremity Nerve Injury: A Systematic Review and Meta-Analysis.

  2024cites this paper
• Civilian ballistic spinal cord injuries versus blunt trauma: comparative analysis of clinical characteristics, management, and outcomes.

  2024cites this paper
• Dental Implant Restoration of a Mandibular Gunshot Injury: A Case Report.

  2024cites this paper
• Diagnostic Challenges in Uncommon Firearm Injury Cases: A Multidisciplinary Approach

  2024cites this paper
• Renal injuries in conflict zones: a 6-year study of traumatic cases in Afghanistan

  2024cites this paper
• Functional and Radiographic Outcomes of Open Proximal Femoral Fractures Caused by Gunshot Wounds in Yemen

  2024cites this paper
• Effects of kinetic energy and firearm‐to‐target distance on fracture behavior in flat bones

  2024cites this paper
• Low energy gunshot injuries: Does removal of retained bullet fragmentation at the time of internal fixation reduce the risk of fracture related infection?

  2024cites this paper
• Ballistic Nerve Injuries: State of the Evidence and Approach to the Patient Based on Experience

  2024cites this paper
• Remarkable Recovery After Severe Gunshot Brain Injury: A Comprehensive Case Study of Functional Rehabilitation

  2024influential citation
• Antibiotic prophylaxis in injury: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document

  2024cites this paper
• MEDICOLEGAL STUDY OF FIREARM DEATHS PRESENTED TO ZEINHOM MORGUE

  2024cites this paper
• Diagnostic and therapeutic considerations in cases of civilian intravascular ballistic embolism: a review of case reports

  2024cites this paper
• The ballistic articular structure injury classification (BASIC) system: clarifying ballistic articular injuries

  2024cites this paper
• Low-cost negative pressure wound therapy for gunshot traumatism in developing countries.

  2024cites this paper
• A Retrospective Study of Ballistic Pelvic Fractures With Focus on Short-Term Clinical Outcomes

  2024cites this paper
• Upper Extremity Ballistic Nerve Injury

  2024cites this paper
• Décès suite à une ischémie cérébrale par sténose carotidienne en rapport avec un traumatisme facial par un fusil de chasse: Rapport de cas autopsique

  2024influential citation
• Biosponge-Encased Placental Stem Cells for Volumetric Muscle Loss Repair

  2024cites this paper
• Blast injuries: The experience of a level 1 trauma center.

  2024cites this paper
• Low-caliber gunshot wounds in the hand a report of three cases.

  2024cites this paper
• Penetrating cardiac injury resulting in a bullet embolus: a case report

  2024cites this paper
• Retained bullets: to remove or not to remove? Lessons from two clinical scenarios with intracardiac bullet embolization

  2024cites this paper
• Pathological Changes and Sodium Rhodizonate Test as Tools for Investigating Gunshot Wounds in Veterinary Forensic Pathology

  2024cites this paper
• Characterizing a Common Phenomenon: Why do Trauma Patients Re-Present to the Emergency Department?

  2024cites this paper
• Costs for Long-Term Health Care After a Police Shooting in Ontario, Canada

  2023influential citation
• Materials for the management of traumatic Wounds: A descriptive review

  2023cites this paper
• REMOVAL OF RETAINED BULLETS FROM THE HIP JOINT IN CIVILIAN GUNSHOT INJURIES

  2023cites this paper
• Management of severe defects of humerus in combat patients injured in Russo-Ukrainian war.

  2023cites this paper
• Management of Gunshot Fractures to the Extremities - A Narrative review

  2023cites this paper
• A 16-Year-Old Ukrainian Boy Shot at Close-Range to the Back of the Neck with a Handgun Who Required Surgical Removal of a 9×18-mm Bullet Shell from the Left Posterior Maxilla and Recovered Following Physical Therapy

  2023cites this paper
• Management of a Transaxial, Tricompartmental Gunshot Injury in a Low-Resource Tertiary-Care Center in the Anglosphere Caribbean

  2023cites this paper
• Spectrum of injuries with “less-lethal” beanbag weapons: pictorial essay

  2022cites this paper
• Alta tasa de complicaciones posoperatorias en fracturas balísticas de fémur distal

  2020influential citation