Skip to main content
SpringerLink
Log in

Indications for bullet removal: overview of the literature, and clinical practice guidelines for European trauma surgeons

  • Original Article
  • Published:
European Journal of Trauma and Emergency Surgery Aims and scope Submit manuscript

Abstract

Purpose

The incidence of gunshot wounds from civilian firearms is increasing. Despite this fact, guidelines on indications for bullet removal are scarce. In this analysis, we combine an overview of the available literature in these rare entities with our experiences in our own clinical practices.

Methods

We conducted a systematic literature search of computerized bibliographic databases (Medline, EMBASE, and the Cochrane Central Register). The local experience of the authors was reviewed in light of the available literature.

Results

145 full-text articles were suitable for further evaluation. Only six retrospective studies were available, and no prospective study could be retrieved. Most of the articles were case reports. In the South African co-author’s own clinical practice, approximately 800 patients are treated per year with gunshot wounds.

Conclusions

In summary, there are only a few clear indications for bullet removal. These include bullets found in joints, CSF, or the globe of the eye. Fragments leading to impingement on a nerve or a nerve root, and bullets lying within the lumen of a vessel, resulting in a risk of ischemia or embolization, should be removed. Rare indications are lead poisoning caused by a fragment, and removal that is required for a medico-legal examination. In all other cases the indication should be critically reviewed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References

  1. Kobbe P, Frink M, Oberbeck R, Tarkin IS, Tzioupis C, Nast-Kolb D, Pape HC, Reilmann H. Treatment strategies for gunshot wounds of the extremities. Unfallchirurg. 2008;111(4):247–54. (quiz 255).

    Article  PubMed  CAS  Google Scholar 

  2. Germanos S, Gourgiotis S, Villias C, Bertucci M, Dimopoulos N, Salemis N. Damage control surgery in the abdomen: an approach for the management of severe injured patients. Int J Surg. 2008;6(3):246–52.

    Article  PubMed  Google Scholar 

  3. Boffard KD. Manual of definitive surgical trauma care. 2nd ed. London: Hodder; 2009.

  4. Brohi K. Indications for bullet removal. http://www.trauma.org/index.php/main/article/601. Accessed 2 June 2011.

  5. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264–9. (W264).

    PubMed  Google Scholar 

  6. Richards JS, Stover SL, Jaworski T. Effect of bullet removal on subsequent pain in persons with spinal cord injury secondary to gunshot wound. J Neurosurg. 1990;73(3):401–4.

    Article  PubMed  CAS  Google Scholar 

  7. Lavy T, Asleh SA. Ocular rubber bullet injuries. Eye (Lond). 2003;17(7):821–4.

    Article  CAS  Google Scholar 

  8. Rehman S, Slemenda C, Kestner C, Joglekar S. Management of gunshot pelvic fractures with bowel injury: is fracture debridement necessary? J Trauma. 2010;71(3):577–81.

    Article  Google Scholar 

  9. Splavski B, Sisljagic V, Peric L, Vrankovic D, Ebling Z. Intracranial infection as a common complication following war missile skull base injury. Injury. 2000;31(4):233–7.

    Article  PubMed  CAS  Google Scholar 

  10. Lee GH, Virkus WW, Kapotas JS. Arthroscopically assisted minimally invasive intraarticular bullet extraction: technique, indications, and results. J Trauma. 2008;64(2):512–6.

    Article  PubMed  Google Scholar 

  11. Shannon FL, McCroskey BL, Moore EE, Moore FA. Venous bullet embolism: rationale for mandatory extraction. J Trauma. 1987;27(10):1118–22.

    Article  PubMed  CAS  Google Scholar 

  12. Cheddie S, Muckart DJ, Hardcastle TC. Direct admission versus interhospital transfer to a level 1 trauma unit improves survival. S Afr Med J. 2011;101:176–8.

    PubMed  CAS  Google Scholar 

  13. Norberg J, Nilsson T, Eriksson A, Hardcastle T. Scientific letter: the costs of a bullet—inpatient costs of firearm injuries in South Africa. S Afr Med J. 2009;(99):442–443.

  14. Veselko M, Trobec R. Intraoperative localization of retained metallic fragments in missile wounds. J Trauma. 2000;49(6):1052–8.

    Article  PubMed  CAS  Google Scholar 

  15. Watters J, Anglen JO, Mullis BH. The role of debridement in low-velocity civilian gunshot injuries resulting in pelvis fractures: a retrospective review of acute infection and inpatient mortality. J Orthop Trauma. 2011;25(3):150–5.

    Article  PubMed  Google Scholar 

  16. Geissler WB, Teasedall RD, Tomasin JD, Hughes JL. Management of low velocity gunshot-induced fractures. J Orthop Trauma. 1990;4(1):39–41.

    Article  PubMed  CAS  Google Scholar 

  17. Howland WS, Jr, Ritchey SJ. Gunshot fractures in civilian practice. An evaluation of the results of limited surgical treatment. J Bone Joint Surg Am. 1971;53(1):47–55.

    PubMed  Google Scholar 

  18. Omoshoro-Jones JA, Nicol AJ, Navsaria PH, Zellweger R, Krige JE, Kahn DH. Selective non-operative management of liver gunshot injuries. Br J Surg. 2005;92(7):890–5.

    Article  PubMed  CAS  Google Scholar 

  19. Windler EC, RB SM, Bryan WJ, Woods GW. Lead intoxication and traumatic arthritis of the hip secondary to retained bullet fragments. A case report. J Bone Joint Surg Am. 1978;60(2):254–5.

    PubMed  CAS  Google Scholar 

  20. Disla E, Brar H, Taranta A. Gouty arthritis following gunshot wound: a case report. N Y State J Med. 1992;92(3):110–1.

    PubMed  CAS  Google Scholar 

  21. Mahirogullari M, Cilli F, Akmaz I, Pehlivan O, Kiral A. Acute arthroscopic removal of a bullet from the shoulder. Arthroscopy. 2007;23(6):676. (e671–673).

    PubMed  Google Scholar 

  22. Borra V, Serra MJ, Rubel IF. Trans-iliac removal of bullet fragments from the sacroiliac joint. J Orthop Trauma. 2006;20(1):52–5.

    Article  PubMed  Google Scholar 

  23. Ho VH, Wilson MW, Fleming JC, Haik BG. Retained intraorbital metallic foreign bodies. Ophthal Plast Reconstr Surg. 2004;20(3):232–6.

    Article  PubMed  Google Scholar 

  24. Mendes PD, Farina EG, de Aguiar GB, Telles C, Acioly MA. Changes in management strategies after spontaneous migration of a retained intraorbital metallic foreign body. J Craniofac Surg. 2010;21(4):1295–6.

    Article  PubMed  Google Scholar 

  25. Waters RL. Gunshot wounds to the spine: the effects of bullet fragments in the spinal canal. J Am Paraplegia Soc. 1984;7(2):30–3.

    PubMed  CAS  Google Scholar 

  26. Cristante AF, de Souza FI, Barros Filho TE, Oliveira RP, Marcon RM. Lead poisoning by intradiscal firearm bullet: a case report. Spine (Phila Pa 1976). 1976;35(4):E140–3.

    Article  Google Scholar 

  27. Waters RL, Sie IH. Spinal cord injuries from gunshot wounds to the spine. Clin Orthop Relat Res. 2003;408:120–5.

    Article  PubMed  Google Scholar 

  28. Madureira PR, De Capitani EM, Vieira RJ, Sakuma AM, Toledo AS, Mello SM. Lead poisoning due to gunshot bullet in contact with cerebrospinal fluid: case report. Sao Paulo Med J. 2009;127(1):52–4.

    Article  PubMed  Google Scholar 

  29. Brandvold B, Levi L, Feinsod M, George ED. Penetrating craniocerebral injuries in the Israeli involvement in the Lebanese conflict, 1982–1985. Analysis of a less aggressive surgical approach. J Neurosurg. 1990;72(1):15–21.

    Article  PubMed  CAS  Google Scholar 

  30. Chaudhri KA, Choudhury AR, al Moutaery KR, Cybulski GR. Penetrating craniocerebral shrapnel injuries during “Operation Desert Storm”: early results of a conservative surgical treatment. Acta Neurochir (Wien). 1994;126(2–4):120–3.

    Article  CAS  Google Scholar 

  31. Taha JM, Saba MI, Brown JA. Missile injuries to the brain treated by simple wound closure: results of a protocol during the Lebanese conflict. Neurosurgery. 1991;29(3):380–3. (Discussion 384).

    Article  PubMed  CAS  Google Scholar 

  32. Nguyen R, Ouedraogo A, Deneuville M. Gunshot wounds to the chest with arterial bullet embolization. Ann Vasc Surg. 2006;20(6):780–3.

    Article  PubMed  Google Scholar 

  33. Keele KL, Gilbert PM, Aquisto TM, Lichtenberg R, Field TC, Lee BK. Bullet embolus to the thoracic aorta with successful endovascular snare retrieval. J Vasc Interv Radiol. 2010;21(1):157–8.

    Article  PubMed  Google Scholar 

  34. Farrell SE, Vandevander P, Schoffstall JM, Lee DC. Blood lead levels in emergency department patients with retained lead bullets and shrapnel. Acad Emerg Med. 1999;6(3):208–12.

    Article  PubMed  CAS  Google Scholar 

  35. Rehani B, Wissman R. Lead poisoning from a gunshot wound. South Med J. 2011;104(1):57–8.

    Article  PubMed  Google Scholar 

  36. McQuirter JL, Rothenberg SJ, Dinkins GA, Kondrashov V, Manalo M, Todd AC. Change in blood lead concentration up to 1 year after a gunshot wound with a retained bullet. Am J Epidemiol. 2004;159(7):683–92.

    Article  PubMed  Google Scholar 

  37. Dada MA, McQuoid-Mason DJ. Medico-legal aspects of trauma and emergency care. Transactions (J Coll Med S Afr). 2004;47(1):57–60.

    Google Scholar 

Download references

Acknowledgments

Thomas Dienstknecht would like to thank the German Trauma Society for granting him the travel award in 2008 and supporting his training period at Tygerberg Hospital in Cape Town, South Africa.

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Trauma, University of Aachen Medical Center, 30 Pauwels Street, 52074, Aachen, Germany

    T. Dienstknecht, K. Horst & R. M. Sellei

  2. Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany

    A. Berner & M. Nerlich

  3. Departments of Health KZN and Surgery, Trauma Service, University of Kwazulu-Natal, Inkosi Albert Luthuli Central Hospital, Durban, South Africa

    T. C. Hardcastle

Authors
  1. T. Dienstknecht
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. K. Horst
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. R. M. Sellei
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. A. Berner
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. M. Nerlich
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. T. C. Hardcastle
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to T. Dienstknecht.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Dienstknecht, T., Horst, K., Sellei, R.M. et al. Indications for bullet removal: overview of the literature, and clinical practice guidelines for European trauma surgeons. Eur J Trauma Emerg Surg 38, 89–93 (2012). https://doi.org/10.1007/s00068-011-0170-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00068-011-0170-x

Keywords

Search

Navigation