Research Article| Volume 28, SUPPLEMENT 3, C23-C28, 1997

The management of retained bullets in the limbs

  • John M. Rhee
    Department of Orthopedic Surgery, San Francisco General Hospital, San Francisco, CA 94110, USA
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  • Robert Martin
    Address for correspondence: Robert Martin, M.D., Associate Clinical Professor, Department of Orthopedic Surgery, University of California, San Francisco, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110, USA
    Department of Orthopedic Surgery, San Francisco General Hospital, San Francisco, CA 94110, USA
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      High energy gunshot wounds are considered contaminated. Wound exploration and aggressive debridement are mandatory, and retained bullets should be removed during this procedure. The majority of civilian gunshot wounds are of low energy, however, and the management of retained bullets in these injuries depends primarily on the location of the missile. In general, bullets retained in soft tissue or muscle can be observed, and if problematic, removed electively when the acute soft tissue swelling has subsided. Bullets that are retained in bone may be followed closely provided that joint violation has been excluded. The current authors recommend prophylactic removal, arthroscopically if possible, of all intra-articular and intra-bursal bullets in order to prevent the devastating complications of lead arthropathy and, less commonly, plumbism. If significant lead deposition already exists within the joint, thorough synovectomy and debridement are necessary. Any joint which has been penetrated by a bullet should be considered for exploration, regardless of the bullet's final position, in order to retrieve bone, cartilage, skin, clothing, and other debris which may remain in the joint. Removal of bullets in patients exhibiting acute lead intoxication should await reduction of serum lead levels. Chelation therapy must continue postoperatively in these patients until total body lead stores have been depleted.


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        • Deitch E.A.
        • Grimes W.R.
        Experience with 112 shotgun wounds of the extremities.
        J. Trauma. 1984; 24: 600-603
        • Shepard G.H.
        High-energy, low-velocity close-range shotgun wounds.
        J. Trauma. 1980; 20: 1065-1067
        • Paradies L.H.
        • Gregory C.F.
        The early treatment of closerange shotgun wounds to the extremities.
        J. Bone Joint Surg. 1976; 48A: 425-435
        • Brettler D.
        • Sedlin E.D.
        • Mendes D.G.
        Conservative treatment of low velocity gunshot wounds.
        Clin. Orthop. 1979; 140: 26-31
        • Howland W.S.
        • Ritchey S.J.
        Gunshot fractures in civilian practice. An evaluation of the results of limited surgical treatment.
        J. Bone Joint Surg. 1971; 53A: 47-55
        • Marcus N.A.
        • Blair W.F.
        • Shuck J.M.
        • Omer G.E.
        Low velocity gunshot wounds to the extremities.
        J. Trauma. 1980; 20: 1061-1064
        • Knapp T.P.
        • Patzakis M.J.
        • Lee J.
        • Seipel P.R.
        • Abdollahi K.
        • Reisch R.B.
        Comparison of intravenous and oral antibiotic therapy in the treatment of fractures caused by low-velocity gunshots.
        J. Bone Joint Surg. 1996; 78A: 1167-1171
        • Beazley W.C.
        • Rosenthal R.E.
        Lead Intoxication 18 months after a gunshot wound.
        Clin. Orthop. 1984; 190: 199-203
        • Grogan D.P.
        • Bucholz R.W.
        Acute lead intoxication from a bullet in an intervertebral disc space: Case Report.
        J. Bone Joint Surg. 1981; 63A: 1180-1182
        • Sclafani S.J.A.
        • Vuletin J.C.
        • Twersky J.
        Lead arthropathy: Arthritis caused by retained intra-articular bullets.
        Radiology. 1985; 156: 299-302
        • Stromberg B.V.
        Symptomatic lead toxicity secondary to retained shotgun pellets: Case Report.
        J. Trauma. 1990; 30: 356-357
        • Philip J.
        Squamous cell carcinoma arising at the site of an underlying bullet.
        J. Royal Coll. Surg. Edinburgh. 1962; 27: 365-366
        • Leonard M.H.
        The solution of lead by synovial fluid.
        Clin. Orthop. 1969; 64: 255-261
        • Linden M.A.
        • Manton W.I.
        • Stewart R.M.
        • Thal E.R.
        • Feit H.
        Lead poisoning from retained bullets: Pathogenesis, Diagnosis, and Management.
        Ann. Surg. 1982; 195: 305-313
        • Janzen D.L.
        • Tirman P.F.J.
        • Rabassa A.E.
        • Kumar S.
        Lead 'bursogram' and focal synovitis secondary to a retained intraarticular bullet fragment.
        Skel. Radiol. 1995; 24: 142-144
        • Peh W.C.G.
        • Reinus W.R.
        Lead arthropathy: a cause of delayed onset lead poisoning.
        Skel. Radiol. 1995; 24: 357-360
        • Primm D.D.
        Lead arthropathy - progressive destruction of a joint by a retained bullet: Case Report.
        J. Bone Joint Surg. 1984; 66A: 292-294
        • Switz D.M.
        • Elmorshidy M.E.
        • Deyerle W.M.
        Bullets, joints, and lead intoxication: A remarkable and instructive case.
        Arch. Intern. Med. 1976; 136: 939-941
        • Viegas S.F.
        • Calhoun J.H.
        Lead poisoning from a gunshot wound to the hand.
        J. Hand Surg. 1986; 11A: 729-732
        • Watson N.
        • Songcharoen G.P.
        Lead synovitis in the hand: A Case Report.
        J. Hand Surg. 1985; 10B: 423-424
        • Windler E.C.
        • Smith R.B.
        • Bryan W.J.
        • Woods G.W.
        Lead intoxication and traumatic arthritis of the hip secondary to retained bullet fragments.
        J. Bone Joint Surg. 1978; 60A: 254-255
        • Cagin C.R.
        • Diloy-Puray M.
        • Westerman M.P.
        Bullets, lead poisoning, and thyrotoxicosis.
        Ann. Intern Med. 1978; 89: 509-511
        • Dillman R.C.
        • Crumb C.K.
        • Lidsky M.J.
        Lead poisoning from a gunshot wound: Report of a case and review of the literature.
        Am. J. Med. 1979; 66: 509-514
        • Machle W.
        Lead absorption from bullets lodged in tissues: Report of two cases.
        JAMA. 1940; 115: 1536-1541
        • Lai C.C.
        Delayed appearance of popliteal cyst caused by a bullet.
        J. Trauma. 1977; 17: 144-150
        • Ashby M.E.
        Low-velocity gunshot wounds involving the knee joint: surgical management.
        J. Bone Joint Surg. 1974; 56A: 1047-1053
        • Jensen S.P.
        • Richardson M.L.
        • Conrad E.U.
        • Lazerte G.D.
        Case Report 608.
        Skel. Radiol. 1990; 19: 233-235
        • Worland R.L.
        Bone cyst following gunshot wound: Case Report.
        J. Trauma. 1975; 15: 613-615
        • Berg E.E.
        • Ciullo J.V.
        Arthroscopic debridement after intraarticular low-velocity gunshot wounds.
        Arthroscopy. 1993; 9: 576-579
        • Bolanos A.A.
        • Demizio J.P.
        • Vigorita V.J.
        • Bryk E.
        Lead poisoning from an intra-articular shotgun pellet in the knee treated with arthroscopic extraction and chelation therapy.
        J. Bone Joint Surg. 1996; 78A: 422-426
        • White R.R.
        Arthroscopic bullet retrieval.
        J. Trauma. 1987; 27: 455-456
        • Goldman A.
        • Minkoff J.
        • Price A.
        • Krinick R.
        A posterior arthroscopic approach to bullet extraction from the hip.
        J. Trauma. 1987; 27: 1294-1300