Search Results (49)

Abdominal arteriovenous fistula [AVF] is a rare but serious complication of penetrating trauma, often associated with high morbidity and mortality. This report presents the case of a 24-year-old male who sustained multiple gunshot wounds, leading to the formation of an ilio-iliac AVF and a pseudoaneurysm. The patient arrived at the emergency department hemodynamically unstable, with bullet wounds to the forearm, thigh, and lumbosacral region. Initial non-arterial phase CT revealed a pseudoaneurysm anterior to the right external iliac vessels and a surrounding hematoma, raising suspicion for AVF. A second biphasic CTA confirmed an AVF connection between the right external iliac artery and external iliac vein, as well as the arterialization of the vein. Additionally, fat stranding and bowel wall thickening suggested potential hollow viscus injury. Due to the patient’s unstable condition and possible intra-abdominal injuries, an open laparotomy was performed. A stent was placed in the right external iliac artery, the vein was primarily repaired, and serosal injuries to the duodenum and cecum were surgically addressed. The patient recovered gradually, although a persistent serous discharge was noted and managed in follow-up. This case highlights the importance of considering AVF in penetrating abdominal trauma and the critical role of biphasic CTA in diagnosis and surgical planning. Full article

Background/Objectives: Artificial intelligence (AI) is beginning to be applied in wound ballistics, showing preliminary potential to improve the accuracy and objectivity of forensic analyses. This review explores the current state of AI applications in forensic firearm wound analysis, emphasizing its potential to address challenges such as subjective interpretations and data heterogeneity. Methods: A systematic review adhering to PRISMA guidelines was conducted using databases such as Scopus and Web of Science. Keywords focused on AI and GSW classification identified 502 studies, narrowed down to 4 relevant articles after rigorous screening based on inclusion and exclusion criteria. Results: These studies examined the role of deep learning (DL) models in classifying GSWs by type, shooting distance, and entry or exit characteristics. The key findings demonstrated that DL models like TinyResNet, ResNet152, and ConvNext Tiny achieved accuracy ranging from 87.99% to 98%. Models were effective in tasks such as classifying GSWs and estimating shooting distances. However, most studies were exploratory in nature, with small sample sizes and, in some cases, reliance on animal models, which limits generalizability to real-world forensic scenarios. Conclusions: Comparisons with other forensic AI applications revealed that large, diverse datasets significantly enhance model performance. Transparent and interpretable AI systems utilizing techniques are essential for judicial acceptance and ethical compliance. Despite the encouraging results, the field remains in an early stage of development. Limitations highlight the need for standardized protocols, cross-institutional collaboration, and the integration of multimodal data for robust forensic AI systems. Future research should focus on overcoming current data and validation constraints, ensuring the ethical use of human forensic data, and developing AI tools that are scientifically sound and legally defensible. Full article

This case report describes index pancreatoduodenectomy in a 32-year-old male following a close-range gunshot wound to the abdomen, with consequent 4 cm pancreatic head defect, duodenal and common bile duct perforation, right kidney laceration, and through-and-through inferior vena cava (IVC) injury. Although standard trauma protocols often favor damage control surgery (DCS) with delayed reconstruction in unstable patients, this patient’s hemodynamic stability—attributed to retroperitoneal self-tamponade—enabled a single-stage definitive approach. The rationale for immediate reconstruction was to prevent the risks associated with delayed management, such as ongoing pancreatic and biliary leakage, chemical peritonitis, and subsequent sepsis or hemorrhage. This case highlights that, in select stable patients with severe pancreaticoduodenal trauma, immediate pancreatoduodenectomy may be preferable to DCS, provided care is delivered in a high-volume hepatopancreaticobiliary (HPB) center with appropriate expertise and resources. Full article

Background: Surgical care in conflict regions like Tigray, Ethiopia, faces severe challenges due to limited resources, infrastructural deficiencies, and high trauma burden. From 2019 to 2023, a multidisciplinary team conducted five humanitarian missions focusing on orthoplastic reconstruction of extremity and mandibular injuries from high-energy gunshot trauma. Methods: A retrospective analysis was performed on 98 patients who underwent free or pedicled flap reconstruction. Data included demographics, flap type, technique, complications, follow-up, and early clinical outcomes score as well as mobility scores. Flaps were harvested using loupes anastomosis performed using microscopes, depending on availability. Results: Among 98 patients (25.5% female, 74.5% male), 69 free flaps and 38 pedicled flaps were performed. Free fibula flaps (n = 54) included 33 mandibular and 21 extremity reconstructions. Additional flaps included ALT, gracilis, and LD flaps. Pedicled flaps included 18 fibula and 20 ALT/LD flaps. Mean age was 35.5 years; mean operative time was 429.5 min, with mandibular fibula transfers being longest. Microsurgical techniques were used in 34% of cases. Median follow-up was 10 months. Microsurgical complications occurred in 18.4%, mainly in fibula transfers (25.9%). Non-microsurgical issues included wound infections (n = 15), graft loss (n = 3), and bleeding (n = 5). Flap loss occurred in 16.3% overall. Early clinical outcome results were good (30.6%), acceptable (28.6%), and moderate (24.5%). Conclusions: Orthoplastic reconstruction using both free and pedicled flaps is feasible in low-resource, conflict settings. Despite infrastructural challenges, functional outcomes were achievable, supporting the value of adaptable microsurgical strategies in humanitarian surgery. Full article

Deep learning has brought substantial progress to medical imaging, which has resulted in continuous improvements in diagnostic procedures. Through deep learning architecture implementations, radiology professionals achieve automated pathological condition detection, segmentation, and classification with improved accuracy. The research tackles a rarely studied clinical medical imaging issue that involves bullet identification and positioning within X-ray images. The purpose is to construct a sturdy deep learning system that will identify and classify ballistic trauma in images. Our research examined various deep learning models that functioned either as classifiers or as object detectors to develop effective solutions for ballistic trauma detection in X-ray images. Research data was developed by replicating controlled bullet damage in chest X-rays while expanding to a wider range of anatomical areas that include the legs, abdomen, and head. Special deep learning algorithms went through a process of optimization before researchers improved their ability to detect and place objects. Multiple computational systems were used to verify the results, which showcased the effectiveness of the proposed solution. This research provides new perspectives on understanding forensic radiology trauma assessment by developing the first deep learning system that detects and classifies gun-related radiographic injuries automatically. The first system for forensic radiology designed with automated deep learning to classify gunshot wounds in radiographs is introduced by this research. This approach offers new ways to look at trauma which is helpful for work in clinics as well as in law enforcement. Full article

The decision to remove a bullet from a gunshot victim depends on its location and associated medical risks, with surgical extraction often not indicated. Radiological imaging plays a vital role in assessing gunshot wounds and locating bullets, and it is essential in both clinical and forensic contexts. This narrative review examines the use of computed tomography (CT) for virtual bullet analysis, providing insights into shape, design, fragmentation, and material composition. Traditional 2D X-ray imaging, though commonly used, has limitations in accurately assessing caliber and position due to magnification and its 2D nature. In contrast, CT scans generate 3D reconstructions for detailed and precise examination, overcoming challenges such as metal artifacts with techniques such as extended Hounsfield unit (HU) reconstructions. These methods enhance the visualization of metal objects, allowing for better analyses of lodged bullets. Dual-energy CT further differentiates materials, such as lead and copper, using HU value differences at two energy levels. These advancements enable the virtual classification, shape analysis, and material identification of bullets in forensic investigations, even when the bullet remains in the body. As CT technology progresses, its forensic applications are expected to improve, providing more accurate and comprehensive differentiations of bullet types in future cases. Full article

Objective: To characterize facial fracture patterns and understand predictors of surgical repair and LOS with the objective of assisting providers in managing and understanding these complex injuries. Study Design: This is a retrospective cohort chart review study. Methods: A retrospective review was conducted for patients admitted with gunshot wounds (GSWs) to the head, neck, or face between January 2013 and March 2020 at a level one trauma tertiary care hospital. Univariate and multivariate analysis were performed to identify associations with surgical repair and LOS. Results: Of the 578 patients with head, neck, or facial GSWs, 204 survived and sustained facial fractures. The maxilla (n = 127, 62%), orbit (n = 114, 55%), and mandible (n = 104, 51%) were the most fractured. Operative rates differed by location (p < 0.001) with highest rates for fractures involving the mandible (76%). In univariate analysis, overall facial fracture surgery was associated with transfacial injuries; mandible, palate and nasal fractures; tracheostomy; gastrostomy tube placement; ICU admission; and a longer-than-24 h ICU stay (all p < 0.05). In multivariate analysis, predictors of surgical repair included a length of stay greater than 3 days (OR 2.9), transfascial injury (OR 3.7) and tracheostomy placement (OR 5.1; all p-values < 0.05), while nasal and mandible fractures were also associated with overall operative repair (OR 2.5 and 9.3, respectively; p-value < 0.05 for both). Univariate analysis showed that among patients with GSW injuries who underwent facial plastic reconstructive surgery (FPRS) with comorbid serious polytrauma, the inpatient LOS was predicted solely by the presence of subarachnoid, subdural and intracranial hemorrhage (p-value < 0.005). Subsequent multivariate analysis found that the only predictor for greater hospital LOS for patients who underwent surgical repair was earlier timing to FPRS of less than five days (OR 0.17) and placement of a gastrostomy tube (OR 7.85). Conclusions: Managing facial fractures in GSW patients requires complex medical decision making with a consideration of functional and esthetic outcomes in the context of concomitant injuries and overall prognosis. Certain characteristics such as ICU admission, longer hospital stay, trajectory of GSW, tracheostomy placement, and specific operative locations are associated with higher rates of operative repair. Inpatient hospitalization LOS for patients who underwent FPRS was predicted by timing from admission to surgical repair. Full article

Background: Firearm wounds tend to have a precise pattern. Despite this, real-world case presentations can present uncertain elements, sometimes deviating from what is considered standard, and present uncommon features that are difficult for forensic pathologists and ballistic experts to explain. Methods: A retrospective analysis of autopsy reports from the Institute of Legal Medicine, University of Catania, covering 2019–2023, included 348 judicial inspections and 378 autopsies performed as part of the institute’s overall activities. Among these, seventeen cases of firearm deaths were identified, with three atypical cases selected for detailed analysis. An interdisciplinary approach involving forensic pathology, radiology, and ballistics was used. Results: The selected cases included: (1) A 56-year-old female with a thoracic gunshot wound involving three 7.65 caliber bullets, displaying complex trajectories and retained bullets; (2) A 48-year-old male with two cranial gunshot injuries, where initial evaluation suggested homicide staged as a suicide, later confirmed to be a single self-inflicted shot; and (3) A 51-year-old male was found in a car with two gunshot wounds to the head, involving complex forensic evaluation to distinguish between entrance and exit wounds and determine trajectory. The findings showed significant deviations from standard patterns, underscoring the critical role of radiological imaging and ballistic analysis in understanding wound morphology and projectile trajectories. Conclusions: This case series highlights the necessity for standardized yet adaptable protocols and cooperation among forensic specialists. A flexible approach allows forensic investigations to be tailored to the specific circumstances of each case, ensuring that essential examinations are conducted while unnecessary procedures are avoided. Comprehensive data collection from autopsies, gross organ examinations, and, when needed, radiological and histological analysis is essential to accurately diagnose injuries, trace bullet trajectories, retrieve retained projectiles, and determine the fatal wound, particularly in complex cases or those involving multiple shooters. Full article

Defense wounds generally occur when a victim attempts to protect vital organs and blood vessels during an assault, and are therefore typically located on the forearms or hands. Gunshot-induced defense wounds are less frequent compared to stab wounds, which have been extensively described in the literature. We present three cases where victims unsuccessfully attempted to defend themselves from gunshots, and where the detailed description of injuries played a key role in the reconstruction of the crime scenes. In the first case, a man was shot with a smooth-bore shotgun, presenting a “through-and-through” gunshot wound on the lateral surface of the left forearm and a large gaping wound on the posterior surface of the same forearm. The second and third cases involved two men who were shot with handguns. The first displayed an entrance wound on the dorsal surface of the right hand, with burned edges and smoke soiling, and an exit wound on the palmar surface. The second case involved two wounds on the left hand: one on the dorsum and the other on the palm. To the best of our knowledge, few studies in the literature emphasize the role of gunshot defense wounds in aiding the reconstruction of crime dynamics. The cases presented in this study highlight the importance of precisely defining the pathological and morphological features of the wounds, as well as the bullet trajectories, to accurately identify defense wounds. These findings are valuable for reconstructing the dynamics of the assault and providing critical information to the public prosecutor. Full article

Gunshot wound morphology and gunshot residues (GSRs) evaluation have been poorly investigated in veterinary forensic pathology. The aims of the present study were to assess the gunshot wound morphology in animals and evaluate the detectability of lead deriving from GSRs using colorimetric techniques. To these aims, cadavers were divided into four different groups. Group A comprised eight animals who died from firearm-related injuries, while groups B and C included dog limbs shot using different shooting ranges; group D comprised dog limbs stabbed with a screwdriver. Morphological analysis was performed on all entry gunshot wounds. Lead residues were investigated using a Bullet Hole Testing Kit (BTK) and Rhodizonate Sodium histochemical staining (NaR-s). Gunshot wounds in group A showed an abrasion ring associated with hemorrhages and tissue necrosis. Groups B and C showed injuries related to the shooting range. NaR-s showed positive results in both animals that died from gunshot wounds and experimentally shot limbs. However, the number of positive cases and the pattern of lead distribution varied with the shooting range. Positive results by BTK were limited to close-contact shots in group B limbs. Our results suggest that both pathological examination and NaR tests represent valid tools for investigating gunshot wounds in veterinary pathology. Full article

The metastasis of poorly differentiated epithelioid carcinoma to the axillary node is uncommon. This tumor has heterogeneous expression and is challenging to diagnose with certainty. Often, it necessitates immunoperoxidase staining to ascertain the tumor lineage, and diagnosis is prolonged due to low suspicion. Herein, we present a case involving a 75-year-old male war veteran with a prior history of a gunshot wound complicated by colostomy that presented with an axillary mass, fecal and urinary incontinence, leg weakness, fevers, night sweats, and substantial weight loss. On admission, he had heightened leukocytosis (43K), anemia (hemoglobin 6.6), and thrombophilia (1000). This patient constantly picked at his back to remove recurrent “gun shrapnel” eruptions. An excisional biopsy of the axillary mass was performed for diagnosis and lymph node removal. Notably, after excision, there was marked improvement in the presenting symptoms. Diagnostic challenges arose due to the tumor cells’ inconsistent immunohistochemical marker expression. The staining patterns alluded to metastatic melanoma. Yet, the tumor displayed epithelial characteristics, supported by an immunophenotypic marker pattern indicative of poorly differentiated carcinoma. This case underscores the morphological and immunoperoxidase staining similarities between poorly differentiated carcinoma and dedifferentiated tumors of varying origins. It illustrates the intricate nature of these malignant metastatic tumors and their overlapping manifestations, which requires provider awareness. The timely diagnosis of poorly differentiated epithelial carcinoma remains paramount to early treatment and improved prognosis. Therefore, in patients manifesting with an axillary mass, fecal and urinary incontinence, and B-symptoms, poorly differentiated epithelial carcinoma should be included in the differential diagnosis. Full article

A penetrating thoracic aorta injury (PTAI) is a life-threatening condition with significant morbidity and mortality, often resulting from several traumatic mechanisms. Among these, gunshot wounds leading to aortic injury are exceedingly rare and pose unique challenges in terms of diagnosis, management, and surgical intervention. We present a case of a 47-year-old male victim of a gunshot wound resulting in penetrating chest trauma and a descending thoracic aorta injury. This report outlines the sequential management involving thoracic endovascular aortic repair (TEVAR), followed by surgical intervention for hematoma drainage and foreign body removal, highlighting the interdisciplinary approach required in managing complex cardiothoracic injuries. Full article

Bleeding resulting from surgical procedures or trauma, including gunshot wounds, represents a life-threatening health issue. Therefore, the development of safe, effective, and convenient hemostatic agents is critical in securing the “golden time” to save patients’ lives. Plant-derived compounds and plant extracts have been regarded as promising sources of hemostatic agents in previous studies, regulating hemostatic function with low toxicity and minimal side effects within the human body. Aloe vera-based hydrogels, which are characterized by flexible strength and high functionality, have emerged as a promising platform for wound applications due to their unique biocompatibility features. This study provides a comprehensive exploration of the utilization of thickening agents and natural agents such as xanthan gum, carrageenan, Carbomer, and alginate in applying aloe vera-based hydrogels as a hemostatic. Furthermore, it also tests the use of aloe vera-based hydrogels for therapeutic delivery at wound sites through the incorporation of various antimicrobial agents to extend the utility of the hydrogels beyond hemostasis. Our novel applied research utilizes aloe vera-based hydrogel as an antimicrobial hemostatic agent, providing valuable insights for a wide range of applications and highlighting its potential to enhance hemorrhage control in various emergency scenarios. Full article

Background: The purpose of this study was to investigate temporal trends in gunshot wound (GSW)-associated orthopedic injuries among children, adolescents, and young adults in New York State, and to determine the impact of the onset of the COVID-19 pandemic on the incidence of these injuries. Methods: The New York Statewide Planning and Research Cooperative System (SPARCS) inpatient database was reviewed to identify patients ≤ 21 years of age who presented to a hospital with GSW-associated injuries from January 2016 to December 2020. Patient diagnosis codes were cross-referenced with the list of the International Classification of Diseases Version 10 Clinical Modification (ICD-10-CM) codes for orthopedic injuries to determine the incidence of GSW-associated orthopedic injuries among this cohort. The number of cases was cross-referenced with New York State census population estimates to calculate incidence per million. The geographic incidence was plotted over a map of New York State with sub-division based on facility Zone Improvement Plan (ZIP) codes. Poisson regression was used to compare the injury incidence in 2020 (pandemic onset) versus the preceding years (pre-pandemic). Results: Between 2016 and 2020, there were 548 inpatient admissions for GSW-associated orthopedic injuries, representing an incidence of 5.6 cases per million. Injury incidence decreased from 2016 to 2019, with an increase in 2020 representing almost 28% of the total cases identified. There was a statistically significant difference in the incidence rate ratio for 2020 compared to 2016–2019 (p < 0.001). The majority of patients were male (94%), African–American (73%), and covered by either Medicare (49%) or Managed Care (47%). Most cases were clustered around large metropolitan areas with low incidence in suburban and rural regions of the state. Conclusions: There was a two-fold increase in the incidence of GSW-associated orthopedic injuries among patients ≤ 21 years old in New York State during the onset of the COVID-19 pandemic. Full article

Antibiotic prophylaxis for extremity gunshot wounds (GSWs) is highly variable. The objective of the present study is to quantify the adherence rate to a protocol for single-dose cephalosporin prophylaxis for extremity GSWs and the impacts on post-injury infection rates. We reviewed patients presenting to a level 1 trauma center with an extremity gunshot wound between 2019 and 2021. Infection rates were compared for patients following the protocol or not, and for patients presenting before or after the protocol’s implementation. Overall, 94% of patients received antibiotic treatment at presentation, but only 34% followed the single-dose antibiotic protocol. The rate of protocol adherence increased from 15% to 39% after the protocol was implemented in the hospital in January 2020 (p = 0.081). Infection rates were not different before and after the protocol implementation (25% vs. 18%, p = 0.45). Infection rates were also not different between patients who did and did not follow the protocol (15% vs. 20%, p = 0.52). The implementation of a single-dose cephalosporin protocol increased adherence to the protocol in a level 1 trauma center without increasing infection rates. These findings support conservative treatment along with a single dose of first-generation cephalosporin antibiotic for uncomplicated extremity GSWs in order to decrease healthcare costs without compromising infection risk. Full article