A young patient (28 years) presented to our casualty with gunshot right chest within 1 hour of injury with stable vitals except tachycardia. The entry wound was in the right lower chest in mid-clavicular line tracting towards right side of abdomen. The bullet was found to lie in the pelvis on x-ray abdomen erect and lateral views but there was no pneumoperitoneum. Patient had right pneumothorax on x-ray of chest. Due to the mechanism of injury, direction of bullet tract and location of bullet, bowel injury and diaphragmatic injury was presumed; and patient underwent laparotomy within 3 hours of injury but per-operatively no bowel, solid organ injury or hemoperitoneum was found. The bullet could be palpated retroperitoneally against the right pubic bone. Limited retroperitoneal exploration on right side which revealed no retroperioteal injury or hematoma. No diaphragmatic rent was found. How this location of bullet can be explained on the basis of above findings? Patient was discharged after 6 days without any complications.
The bullet coursed in the extrapleural space, which was continuous with the retroperitoneal space, and stopped beside the right pubic bone. The pneumothorax, if NOT accompanied by hemothorax, indicated the thermal injury when the bullet entered the extrapleural space and got in contact with the lung instead of going thru the lung.
I went into a gunshot patient about 10 years ago who was shot in the right upper abdomen but the bullet coursed in the extraperitoneal space and stopped beside the right pubic bone without organ injury.
She underwent a CT scan then, which revealed the trajectory of the bullet inside her body.
Retroperitoneal space is a dense space with many vital structures (aorta, IVC, part of liver, kidney, adrenal gland, ureter and many other vascular structures). Sir (Yi-Ting Yen and Zuidema), you have indeed presented interesting theories. I was plannnig to report this case but could not understand the exact mechanism. Infact I am glad that I am not the only one who encountered such a case. Thanks a lot.
it is possible: the weapon wounded are treated for their presentations, this patient didn't have danger signs except pneumothorax: I suggest you look at the description on how bullets cause tissue injuries in 'ballistic medicine' to enrich your planned case-report.
Did this get published? Am I to understand that the wound trajectory is almost vertical? If so, we may have another "Space Bullet" which is a low velocity bullet and can travel alone the path of least resistance, thus dissecting a path along tissue planes, and may miss major structures as it does not follow a straight line. This should be visualized well on a 3-D CT scan. You can read the full-text on "Spent Bullets" here on RG; which explains the research on a large series of the first published cases. Thank you for your support, Gary Ordog, MD
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