F o r e n s i c R a d i o l o g y • P i c t o r i a l E s s ay
Harcke et al.
MDCT of Projectile Injury
Forensic Radiology
Pictorial Essay
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H. Theodore Harcke1,2
Angela D. Levy 2
John M. Getz 3
Stephen R. Robinson 3
Harcke HT, Levy AD, Getz JM, Robinson SR
Keywords: forensic autopsy, MDCT, projectile injury
DOI:10.2214/AJR.07.2754
Received June 19, 2007; accepted after revision
August 16, 2007.
The opinions or assertions contained herein are the
private views of the authors and are not to be construed
as official or as reflecting the views of the Departments
of the Army, Navy, or Defense.
1
Department of Radiologic Pathology, Armed Forces
Institute of Pathology, Washington, DC. Address
correspondence to H. T. Harcke, c/o Michelle Stofa,
PO Box 269, Wilmington, DE 19899
(howard.harcke@us.army.mil).
2
Department of Radiology, Uniformed Services University
of the Health Sciences, Bethesda, MD.
3
Office of the Armed Forces Medical Examiner, Armed
Forces Institute of Pathology, Rockville, MD.
WEB
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W106 AJR:190, February 2008
MDCT Analysis of Projectile
Injury in Forensic Investigation
OBJECTIVE. This article illustrates the MDCT postmortem imaging features that have
the potential to enhance forensic investigation and conventional autopsy.
Conclusion. MDCT may guide, direct, or limit forensic autopsy in projectile injury
cases, thereby eliminating the need for a complete invasive autopsy.
M
DCT is an effective imaging tech-
nique to localize gunshot wound
tracks and aid in the forensic au-
topsy of gunshot wound victims
[1–3]. Projectiles include a diverse group of
metallic objects such as bullets, components
of explosive devices, or secondary projectiles
from explosions that may inflict injury or
cause death. In the forensic investigation of
death by suspected projectile injury, deter-
mination of the projectile’s entry and exit
locations, path, and associated tissue injury
is important in the determination of the cause
and manner of death [4, 5].
The purpose of this article is to illustrate
the noninvasive characterization of projec-
tile wounds on postmortem full-body, thin-
section MDCT images. In all cases, imaging
was performed on a 16-MDCT scanner. Im-
ages were interpreted using multiplanar 2D
reconstruction, minimum intensity projec-
tion, and 3D volume rendering to critically
and accurately analyze the 3D paths and fea-
tures of projectile injury.
The study was performed with the ap-
proval of the institutional review board of
the Armed Forces Institute of Pathology and
was HIPAA-compliant. Total-body MDCT
scans were obtained on a LightSpeed 16 (GE
Healthcare) within 2–4 days after death.
Subjects were scanned at 1.25 × 0.625 mm;
pitch, 0.935:1; rotation speed, 0.5 second;
and table speed, 17.2 mm per rotation. Imag-
es were viewed and measured on an Advan-
tage Workstation, software version 4.2 (GE
Healthcare), using 2D and 3D multiplanar
reconstructions.
Projectile Injury
Projectile injury is classified by the location
of the entrance and exit wounds and the course
of the projectile path. The projectile path is
customarily described in three directions, de-
fining the direction of projectile travel. The
description indicates whether the projectile
enters the body from anterior or posterior, left
or right, and superior or inferior. The presence
or absence of foreign material within the body
(e.g., bullet, metallic fragment, or other ma-
terial) is always noted and characterized be-
cause recovery of fragments is important for
ballistics documentation.
Entrance wounds are usually smaller than
exit wounds [5]. When a bullet has passed
through bone, close examination may show
beveling of the bone in the direction of
travel. Beveled edges are directed inward at
the bone margin of the entrance wound and
directed outward at the exit wound [5]. Me-
tallic particles and bone fracture fragments
are an additional indicator of directionality
because they are usually carried along the
direction of projectile travel. If a projectile
fragments, pieces of metal will be distribut-
ed along the track and mix with bone frag-
ments (Fig. 1).
Wound tracks through soft tissue are char-
acterized by gas collections or evidence of
tissue and organ damage [3]. Postmortem gas
collections in a wound track may result from
the temporary cavities created when projectile
energy is transmitted to the tissue surround-
ing the track. Gas may also be introduced
along the track when the projectile passes
through an air- or gas-containing organ, such

as lung and bowel. Because gas readily dis-
sects through tissue planes, scattered gas col-
lections may also be noted in surrounding
tissues. Generalized decomposition also pro-
duces tissue gas and should not be confused
with a wound track. A collection of blood and
other body fluids can occur in the wound track
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or pool away from it (Fig. 2).
Penetrating Wounds
When projectiles enter the body but do not
exit, forensic pathologists term these “pene-
trating wounds” [5] (Figs. 3 and 4). The projec-
tile can remain intact or be fragmented within
the body. Wound track direction can change
depending on the shape and kinetic energy of
the projectile and its interaction with tissue,
especially bone. When interpreting postmor-
tem CT images, it is important to remember
that a straight-line path between an entrance
wound and the postmortem position does not
necessarily represent the antemortem path
of the projectile because the trajectory may
have been altered by the intervening tissues.
Intermediate targets such as bone may pro-
duce a ricochet phenomenon within the body.
Moreover, organ size and shape often change
postmortem (for example, lung volume may
be altered by a pneumothorax or hemothorax
caused by projectile injury) [2, 3].
Perforating Wounds
When projectiles enter and exit the body,
forensic pathologists term these “perforating
wounds” [5] (Fig. 5). The projectile may exit
without fragmentation, in which case there
is residual material, or, similar to the tracks
of penetrating wounds, projectile fragments
may be deposited within the tissue. Analy-
sis of postmortem CT images should always
consider the position of the body at the time
of injury, especially when entry and exit
wounds do not match other points on the
track, such as fractures. This should raise
suspicion that the postmortem position is sig-
AJR:190, February 2008 W107
MDCT of Projectile Injury
nificantly different from the position of the
body at the time of injury [5] (Fig. 6).
Combination Wounds and
Special Cases
Projectiles that break into several frag-
ments within the body may create secondary
penetrating wounds. In such cases, a single
entry wound can become a series of penetrat-
ing wounds with retained fragments along
one or more secondary perforating wounds.
One or more fragments may continue and
pass outside the body. Thus, there may be one
entry site and more than one exit site.
“Keyhole fractures” of the skull are a spe-
cial type of perforating wound in which the
entry and exit are close together. These occur
when the projectile strikes the surface of the
calvaria in a tangential manner. The entry is
the smaller part of the keyhole, and the exit
is the larger (Fig. 7).
Limitations of MDCT Analysis
of Projectile Injury in Forensic
Investigation
Soft-tissue differentiation between organs
and vascular structures is poor on postmor-
tem CT images because of the lack of IV con-
trast material. Consequently, vascular injury
is often undetected. However, the detection of
hematomas or gas or fluid collections in the
course of a wound track permits prediction of
vascular injury. Postmortem angiography can
augment MDCT for the assessment of vascu-
lar integrity [6].
Gas associated with projectile tracks is
variable. The amount of gas within the projec-
tile path depends on the anatomic structures
involved and the ballistic characteristics of a
particular projectile.
Wounds easily visible on gross inspection
may be subtle or not present on MDCT be-
cause entry and exit wound characteristics
may change due to effects such as extrinsic
pressure from an adjacent body part, cloth-
ing, and dependent postmortem positioning.
In some cases, 3D surface rendering may be
helpful to show wounds not easily seen on 2D
reconstructions [2].
MDCT is typically performed with the vic-
tim in the supine position. Projectile tracks are
related to the position of the victim at the time
of lethal injury and may be difficult to appre-
ciate in the postmortem supine position (Fig.
6). Specifically, the lungs, mediastinum, and
heart may be shifted significantly during or
after death by hemorrhage or pneumothorax.
Conclusions
Applying essential concepts of projec-
tile trajectory and track analysis to MDCT
permits characterization of penetrating and
perforating injuries. Postmortem MDCT is a
noninvasive technique with the potential to
enhance forensic investigation and conven-
tional autopsy.
References
1. Thali MJ, Yen K, Vock P, et al. Image-guided vir-
tual autopsy findings of gunshot victims per-
formed with multi-slice computed tomography
and magnetic resonance imaging and subsequent
correlation between radiology and autopsy find-
ings. Forensic Sci Int 2003; 138:8–16
2. Levy AD, Abbott RM, Mallak CT, et al. Virtual au-
topsy: preliminary experience in high-velocity gun-
shot wound victims. Radiology 2006; 240:522–528
3. Harcke HT, Levy AD, Abbott RM, et al. Autopsy
radiography: digital radiographs (DR) vs. multide-
tector computed tomography (MDCT) in high-
velocity gunshot-wound victims. Am J Forensic
Med Pathol 2007; 28:13–19
4. Brogdon BG. Forensic radiology. Boca Raton, FL:
CRC Press, 1998
5. Di Maio VJM. Gunshot wounds: practical as-
pects of firearms, ballistics, and forensic tech-
niques. Boca Raton, FL: CRC Press, 1999
6. Grabherr S, Djonov V, Yen K, Thali MJ, Dirnhofer
R. Postmortem angiography: review of former and
current methods. AJR 2007; 188:832–838
 Harcke et al.
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A B C
Fig. 1—Single gunshot wound to head.
A, Three-dimensional reconstruction image shows midline frontal entrance (solid arrow) and right occipital exit (dashed arrow).
B, Axial CT image shows frontal entrance wound has internal beveling (arrowheads) and occipital exit wound has external beveling (arrows).
C, Reconstructed oblique sagittal image shows bone and metallic fragments are distributed along track within soft tissue.

A B
Fig. 2—Gunshot wound to chest. Images show evidence of tissue and organ damage and bone interaction with
bilateral pleural fluid.
A, Axial image of chest shows wound entrance in right chest wall (arrow). Bullet passes through posterior
mediastinum (arrowhead).
B, Axial image of abdomen shows left lower rib fracture at site of exit (arrow).

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C
Fig. 3—Penetrating projectile injury of head.
A, Three-dimensional reconstruction of skull shows
occipital entry fracture defect.
B, Coronal reconstruction image shows projectile in
right parietal lobe (arrow).
C, Sagittal oblique reconstruction image shows
wound path is determined by bone fragments along
right petrous ridge and high-attenuation hemorrhage
in wound path (arrowhead). Projectile struck petrous
bone after entry and changed direction to its final
location. Note bone fragments adjacent to right
petrous bone (arrow).
C E
Fig. 4—Penetrating projectile wound of head.
A, Photograph shows entry wound through nose.
B, Sagittal reconstructed CT image shows projectile wound track passes into posterior fossa through inferior
portion of petrous ridge. Nonlinear path of projectile indicates that it was diverted by impact on occipital bone.
C, Sagittal reconstructed CT image shows final position of projectile.
D, Photograph shows gross pathology. Note right petrous fracture at skull base (arrow).
E, Photograph shows recovered projectile.

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A B C

D E F
Fig. 5—Perforating gunshot wound of head and neck.
A, Photograph shows entrance wound of left cheek.
B, Coronal CT image at entry shows fractures of left mandible (arrow).
C, Coronal CT image shows C2 and C3 fractures and wound track (arrows).
D, Coronal CT image shows exit wound in right track (arrow).
E, Photograph shows exit wound.
F, Oblique sagittal reconstruction image approximating wound track.

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A B C
Fig. 6—Perforating gunshot wound of thorax.
Postmortem CT shows malalignment of three distinct
landmarks in wound path.
A, Axial CT image shows entrance wound in anterior
left chest (arrowhead). Note right pneumothorax and
bilateral hemothoraces.
B, Axial CT image shows path crosses mediastinum
and exits through right posterior rib (arrowhead).
C, Axial chest CT image shows fracture defect in
right scapula. Note this image is more cranial than
where rib fracture occurred.
D, Three-dimensional reconstruction image of thorax
viewed from posterior shows bone fracture defects
in right sixth rib and medial margin of right scapula.
Note malalignment in autopsy position.
E, Autopsy photograph shows rod demonstration
of wound track. Note that with flexion of upper arm,
scapula rotates, and alignment is achieved.

D E

A B

Fig. 7—Keyhole fracture of skull caused by tangential

gunshot.
A, Sagittal reconstruction image at entry impact
shows internal beveling (arrows).
B, Sagittal reconstruction image at exit shows larger
defect and external bevel (arrows).
C, Three-dimensional reconstruction image of skull
shows smaller entry (arrows) and larger exit.
D, Photograph shows gross pathology.
C D

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