Characteristics of Ballistic and Blast Injuries

David B. Powers, DMD, MD, FACS, FRCS (Ed) a,*, Robert I. Delo, DDS, MD b

KEYWORDS
 Facial  Maxillofacial  Ballistic  Blast  Soft tissue injury  Bone injury

KEY POINTS
 The permanent cavity is the site of initial permanent tissue destruction.
 Deformation of the projectile after impacting hard tissues causes an increase in the size of the permanent cavity.
 After striking bone, fragmentation of the projectile and/or bone can result in the formation of numerous secondary
projectiles each producing additional wounding potential, enlarging the size of the permanent cavity.
 The ultimate fate and compositional makeup of the projectile is more important than its velocity or caliber.
 Soft tissue injuries inherent in ballistic trauma may exhibit avulsive loss, sequential necrosis over days to weeks, and
compromised vascularity, negating/delaying potential microvascular or pedicled soft tissue reconstruction.

Introduction energy transmitted from a high-velocity projectile does not

Ballistic injury patterns to the craniomaxillofacial region present
a unique, and challenging, dilemma for the facial trauma
surgeon. The tissue disruption associated with ballistic injury to
the head and neck region can be daunting, and the identification
of normal anatomic planes, potentially lost within bleeding,
destroyed soft and hard tissues can challenge the skills of even
the most experienced facial trauma specialist. Although classi-
cally considered under the purview of the military trauma
surgeon, ballistic and blast injuries also are routinely treated by
the civilian surgeon because of the incidence of intentional and
unintentional firearm injuries and industrial accidents. A basic
understanding of the definitions and characteristic clinical find-
ings of ballistic and blast wounds should be an important tool in
the armamentarium of the practicing craniomaxillofacial trauma
surgeon.
Introduction to commonly used ballistic terms
Any introduction to the study of ballistic injuries should
provide a review of commonly used terms. Table 1 provides the
necessary background information to recognize the termi-
nology associated with ballistics, and how those components
correlate to an understanding of ballistic injuries:
As historical concepts of ballistics teach that impact kinetic
energy is equal to one-half the mass of the projectile times
velocity squared (KE Z ½ MV2), one would wrongly assume
caliber (size) of the projectile and velocity are the sole
components of injury calculation. Actually, the increased
a
Duke Craniomaxillofacial Trauma Program, Division of Plastic,
Reconstructive, Maxillofacial and Oral Surgery, Duke University Medical
Center, DUMC Box 2955, Durham, NC 27710, USA
b
59th Medical Wing/Department of Oral and Maxillofacial Surgery,
2200 Bergquist Drive, Suite 1, Lackland AFB, TX 78236, USA
* Corresponding author.
E-mail address: David.Powers@duke.edu
necessarily translate to increased wounding capacity, as will be
noted throughout the remainder of this article, and the physical
properties of the projectile, and its fate on striking the victim,
are more important than the caliber. Caliber alone has no
alteration to the surgical treatment of the injury, and primarily
serves to satisfy the curiosity of the attending medical staff. By
understanding the basic mechanical properties of the projectile
expelled toward the target, the correlation of velocity and
subsequent energy transfer, and the anatomic properties of the
head and neck, the craniomaxillofacial trauma surgeon will have
a better understanding of the consequences of ballistic injury to
the facial skeleton (Box 1).
Yaw, precession, and nutation are frequently referenced
when initially studying ballistics. Yaw and precession decrease
as the distance of the bullet from the barrel increases, and along
with nutation, are terms generally associated with shooting
from a distance, as seen in military-grade artillery weaponry
(Fig. 1). Illustrative examples of yaw are exaggerated in excess
of 30
for graphic representation, while in actuality the degree
of yaw is generally less than 1
to 2
, affording tight control of
the projectile in flight and allowing the projectile to hit what the
firearm is aimed toward. Should the yaw be as exaggerated as
seen in most artistic renderings, the projectile would be
uncontrollable because of tumbling along the path of fire. A
clear clinical example of the effects of yaw and precession is
that when examined on a shooting range, projectile holes in
targets are consistently circular in nature, indicating the
spherical shape of the projectile, not a ragged opening consis-
tent with “tumbling” or excessive yaw. Of interest, projectiles
do tumble within the body of the target, causing increased
damage after striking hard tissue, or with deformation of the
projectile. Although these terms have practical applications in
weaponry, the clinical significance of these items in cranio-
maxillofacial ballistic trauma is negligible at best.
The magnus and coriolis effects are also frequently refer-
enced in the discussion of ballistics, but again are isolated to
the military applications of projectile flight, as well as the
recreational aspects of long-range firing for hunting or
competitive shooting. As the overwhelming majority of ballistic

Atlas Oral Maxillofacial Surg Clin N Am 21 (2013) 15e24

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16 Powers & Delo

Table 1 Commonly used terms in ballistics

Components of ammunition
Cartridge/Round A unit of firearm ammunition
Projectile The component of the round that is expelled toward the target, sometimes referred to as the “bullet”
Magnum A cartridge loaded with either a greater volume or more powerful propellant than the original cartridge design,
imparting greater velocity to the projectile
Components of weapon
Rifling Helical grooves in the barrel of a weapon, which imparts spin along the long axis of the projectile
Caliber The internal diameter of the barrel of a weapon, usually measured in millimeters or fractions of an inch
Gauge/Bore The total number of round lead balls that would fill the diameter of the barrel and weigh 1 pound
Associated terms seen in ballistic literature
Yaw Movement along the longitudinal access of the projectile
Precession Rotation of the projectile around the center of mass
Nutation Small circular movement along the projectile tip
Magnus effect Lateral crosswind effect of a spinning projectile in flight
Coriolis effect Spherical shape and rotational properties of the Earth, and its orbit, as it applies to the projectile

injuries to the head and neck region occur within relatively
short distances, well within the effective range of the weapon
and projectiles, these definitions and concepts have minimal to
no correlation to the remainder of this article, or for the
surgical management of these ballistic injuries.
Components of ballistic missiles
As previously described, the cartridge or round describes a unit
of firearm ammunition. Each round consists of the following
(Fig. 2):
 Projectile
 Casing
 Propellant
 Primer
The components of a round provide a basic understanding of
the principles of firearm injury. The projectile is the portion of
the bullet that is expelled and strikes the target. The composi-
tional makeup of the projectile (soft lead, hollow point, full
copper covering, or multiple pellets, as seen in shotguns) has
a direct correlation on the wounding potential of the weapon. As
a projectile deforms after striking the victim, either as a result of
metallurgic composition during manufacturing, or as a direct
consequence of striking the underlying bone, the energy transfer
to the victim, and potential injury to associated tissues, is
increased. As noted earlier, the actual projectiles expelled by
firearms are limited in type only by the imagination of the
manufacturers and firearm enthusiast. The casing is the
container packaging the projectile, propellant (gunpowder or
cordite), and primer as a single unit for placement into the firing
mechanism of the weapon. The propellant, such as gunpowder or
cordite, is the accelerant that actually allows for expulsion of the
projectile from the weapon. The more propellant in a cartridge,
as is seen in magnum and rifle rounds, the greater velocity the
projectile exhibits. Wadding, or wads, are generally plastic
frameworks with a paper or felt insert that hold the various
pellets (projectiles) together in relation to the propellant,
allowing for accurate and safe release of all the projectiles
simultaneously from the barrel in scattershot and shotgun
cartridges. Without the presence of wadding, the gas produced
by the propellant would push through the pellets, and not propel
them as a unit. The primer is the only portion of the bullet with an
explosive charge. As the primer is struck by the firing pin of the
weapon, the explosive charge is activated, igniting the propel-
lant and sending the projectile on its flight. Some cartridges are
referred to as rimfire, as the priming mechanism is contained
within the rim of the base rather than a separate primer in the
center of the base. Generally, rimfire cartridges are less powerful
and cannot be reloaded, whereas centerfire cartridges can have
the primer replaced and reloaded with another projectile.
Rifles, handguns, and machine guns have rifled barrels;
essentially, spiral grooves cut into the length of the interior of the
YAW

PRECESSION
Box 1. Factors affecting energy transfer
between a projectile and body tissue
Velocity
Profile
Shape
Stability NUTATION
Fragmentation
Expansion Fig. 1 Yaw: Movement along the longitudinal access of the
Secondary impact projectile; precession: rotation of the projectile around the center
of mass; nutation: small circular movement along the projectile tip.
Characteristics of Ballistic and Blast Injuries
Fig. 2 (A) Cross-sectional analysis of a cartridge and shotgun
shell. (B) Cross-section of a full-metal jacketed rifle cartridge.
bore of the barrel. The grooves impart spin upon the projectile,
stabilizing it in flight and allowing the projectile to travel in
a controlled manner to the target. The grooves are separated by
segments of metal, called lands, which project into the middle of
the barrel. The diameter of the barrel measured between the
lands represents the caliber of the projectile. Caliber specifica-
tions based on nomenclature used in the United States can be
difficult to comprehend, and utterly confusing to the health care
team. The 0.30-06 and the Winchester 0.308 cartridges are both
loaded with bullets that have a diameter of 0.308 inches. The
‘‘0600 in this term describes the year, 1906, when the cartridge
was introduced to the market. The term ‘‘grains’’ originally was
applied to black powder charges and refers to the weight of the
powder in the cartridge, not the number of granules contained in
the cartridge case. A 0.30e30 cartridge has a 0.308-inch-diam-
eter bullet propelled by 30 grains of smokeless powder. As newer
forms of gunpowder were developed, this powder charge was no
longer used, but the terminology persists to this day. Additional
misperceptions regarding caliber exists because the North
Atlantic Treaty Organization (NATO) and US military projectiles
are described using the metric system (7.62-mm or 9.00-mm
rounds), whereas US civilian firearm munitions are generally
referred to in measurements relating to inches (0.357 or 0.38).
Unfortunately, no uniform mechanism exists for the description
of firearm cartridges and manufacturers continue to inundate the
market with further descriptions to add to the confusion, such as
velocity, country of manufacture, number of grains of propel-
lant, year of manufacture, and so forth (Fig. 3). As noted earlier,
the question regarding caliber is commonly asked in the
management of ballistic injury. In reality, caliber has minimal
practical impact in the care of the patient, as the surgical
management of a wound caused by a 0.357 projectile is no
different from a wound caused by a 9-mm round, and should be
directed to the specific anatomic anomaly created by the
17
Fig. 3 The tremendous variety of caliber, projectile composition
or construction, and variable volumes of propellant and casings
available for the modern firearm. (From Powers DB, Delo RI.
Maxillofacial ballistic and missile injuries. In: Fonseca RJ, Walker
RV, Betts NJ, et al, editors. Oral and maxillofacial trauma. 4th
edition. St Louis (MO): Elsevier Saunders; 2012; with permission.)
projectile, not the weapon used. Experienced surgical providers
cannot accurately determine the caliber of a weapon by visual
examination of the wound alone, and would never alter the
required treatment based on the diameter of the projectile.
Handguns are handheld firearms, with a barrel length gener-
ally 10.5 inches or smaller, which usually fire projectiles of
a lower velocity and caliber. Handgun injuries generally have
a tendency to “push-away,” or stretch soft tissues, including
vessels or nerves, as opposed to avulsive loss. The characteristic
low-velocity wound has a small, rounded, or slightly ragged
entrance wound, causing fragmentation of teeth and bony
comminution, often exhibiting no exit wound (Fig. 4AeC). If an
exit wound does occur, it is generally slit-shaped or stellate.
Rifles are long guns with barrel lengths generally longer than 24
inches. At distance, rifle wounds create a low-energy transfer
similar to those seen with handguns. At close range, the
wounding characteristics are different because of the increased
potential injury associated with velocity and high-energy trans-
fer (see Fig. 4DeH). The presence of an exit wound is usually
found, which may be stellate and larger than the entry wound.
The existence of avulsive soft/hard tissue wounds and significant
fragmentation of the bone can be characteristic findings of rifle
wounds. A shotgun is a long gun that may fire a single pellet, or
numerous pellets, at a relatively low velocity. The gauge of the
shotgun is classified as the number of lead balls/pellets placed
together, equaling the interior diameter of the barrel, which
would weigh 1 pound. For contact with close-range injuries, the
effect of the gas that is discharged under pressure into the wound
also needs to be considered. This scenario is extremely important
in shotgun and improvised explosive blast wounds because of the
higher degree of contamination and presence of propelled gas
and shock waves. Powder gases are expelled from the muzzle of
the weapon after combustion of the gunpowder and follow the
projectile out of the barrel. When the muzzle of the weapon is in
contact with the target, this can be an additional source of tissue
displacement, injury, and thermal burning.
Shotgun pellet injuries essentially depend completely on the
distance the weapon is from the target at the time of discharge.
Sherman and Parrish devised a classification system to describe
18 Powers & Delo

Fig. 4 (A) Characteristic clinical appearance of low-energy/low-velocity gunshot wound to the anterior mandible. No exit wound was
detected. (B) Three-dimensional reconstruction of computed tomography scan indicating the degree of comminution associated with this
gunshot wound. Three-dimensional reconstructions provide superior visualization, and localization, of anatomic variants in the
management of ballistic injuries to the craniomaxillofacial unit. (C) Application of a modern external fixator for the management of a low-
energy/low-velocity gunshot wound to the mandible. Note the conservative treatment of the gunshot wound, with minimal decontami-
nation/debridement. (D) High-energy/high-velocity rifle wound to the anterior maxilla with complete avulsion of the nasal complex. Note
the significant difference in the wounding characteristics of the high-energy weapon, as the patient was shot in the face at a distance by
an assailant with a rifle. Reconstruction shows use of calvarial bone to reconstruct the vertical pillars of support for the maxilla. (E) High-
energy gunshot wound to the anterior mandible. Note the presence of soft tissue disruption as the projectile exited the patient’s mouth
and then tracked along the soft tissues of his anterior maxilla. (F) Three-dimensional reconstruction of computed tomography scan
indicating the degree of comminution and avulsive bone loss associated with this gunshot wound. (G) Initial stabilization of the patient was
accomplished with an external fixator. (H) Definitive reconstruction with open reduction and internal fixation with a reconstruction plate.
([D] From Powers DB, Delo RI. Maxillofacial ballistic and missile injuries. In: Fonseca RJ, Walker RV, Betts NJ, et al, editors. Oral and
maxillofacial trauma. 4th edition. St Louis (MO): Elsevier Saunders; 2012; with permission.)

shotgun wounds in relation to the distance from the target. Type I
injury occurs from a distance longer than 7 yards; type II injury is
sustained when the discharge is within 3 to 7 yards; type III injury
is within 3 yards. Type III injuries usually sustain dramatic soft and
hard tissue injuries and avulsion of tissue, whereas type I injuries
may be minimal (Fig. 5). Because victims often have difficulty in
determining how far away the shotgun was at the time of
discharge, Glezer and colleagues revised this classification
system and directed their attention to the size of the pellet
scatter. Type I injuries occur when pellet scatter is within an area
of 25 cm2; type II injuries are within 10 cm2 to 25 cm2; type III
injuries have pellet scatter less than 10 cm2. Although the Glezer
classification originally was developed for abdominal injuries,
the information is transferable to other areas of the body, and
determinations of tissue injury can be correlated directly to the
size of the pellet scatter. Intuitively, the closer the shotgun is to
the patient, the more dramatic is the hard and soft tissue
damage. For rifles and handguns, the practical clinical difference
in whether the weapon was 10 feet, 100 feet, or 1000 feet away
from the patient otherwise has no bearing on surgical and
medical treatment.
Components of improvised explosive devices
The current conflicts in the Middle East have introduced a “new”
mechanism for delivery of maxillofacial missile projectiles,
resulting in gruesome and avulsive craniomaxillofacial injuries,
the improvised explosive device (IED). Although not a new entity,
as the concept of IEDs has been deployed by guerilla forces since
World War II, the description and media interest in the IED
warrants a brief discussion of its characteristic properties.
Explosives are broadly classified as low-order explosives (LE,
such as pipe bombs, gunpowder, or petroleum-based bombs) or
Characteristics of Ballistic and Blast Injuries 19

Fig. 5 (A) Characteristic facial appearance of a patient sustaining a shotgun wound from a distance (Sherman and Parrish e Class I or
Glezer e Class I). Note the presence of multiple punctate entry wounds, but no significant disruption of the facial features. (B, C) Classic
radiographic appearance of a patient sustaining a shotgun wound from a distance (Sherman and Parrish e Class I or Glezer e Class I). Note
the presence of multiple shotgun pellets on the radiographs. (D) Self-inflicted shotgun wound in a suicide attempt. Note significant hard
and soft tissue disruption and avulsion (Sherman and Parrish e Class III or Glezer e Class III). ([A, D] From Powers DB, Delo RI. Maxillofacial
ballistic and missile injuries. In: Fonseca RJ, Walker RV, Betts NJ, et al, editors. Oral and maxillofacial trauma. 4th edition. St Louis (MO):
Elsevier Saunders; 2012; with permission.)

high-ordered explosives (HE, such as TNT, C4, Semtex). Addi-
tionally, explosives are categorized as manufactured, which
implies military-grade mass production and quality control, or
improvised. An IED is a bomb fabricated in an “improvised”
manner designed to destroy or incapacitate military personnel or
civilians. The bomb itself may be a conventional military-grade
weapon, or an assortment of explosive components, such as
gasoline, or agricultural fertilizer, as seen in the Oklahoma City
bombing of 1995. An IED has 5 components (Fig. 6):
proximity of the victim to the site of the explosion, the greater
the exposure to the shock wave energy. The initial shock wave
of very high overpressurization, which is referred to as the
primary, or “blast wave”, is unique to the HE and is followed
closely by a “secondary wind,” a huge volume of displaced air
flooding back into the area, again under pressure. It is these
sudden and extreme differences in pressures, and associated

 Switch (activator)
 Initiator (fuse)
 Container (body)
 Charge (explosive)
 Power source (battery)

Antipersonnel IEDs typically contain shrapnel, generating

components such as nails, ball-bearings, metal fragments,
wood, or glass. The victim may first sustain a burn injury from
ignited explosives. Blunt and penetrating injury from contact
by exploded fragments will further injure the patient. These
fragments will be propelled at high or ultra-high velocity and
therefore cause ultra-high kinetic energy injuries. Direct
shrapnel injury is only a single element to be considered, as
detonation of any powerful explosive generates a blast wave of
high pressure that spreads out from the point of explosion and
travels hundreds of yards in all directions. The relative Fig. 6 Components of an IED.
20 Powers & Delo

Fig. 7 (A) Wounding potential of an IED. (B) Characteristic facial injuries sustained by an improvised explosive device. ([A] From
Emergency War Surgery Course. Washington, DC: US Government; 2009.)

dispersal of secondary projectiles, which can lead to significant
neurologic, skeletal, or soft tissue injury (Fig. 7, Tables 2 and 3).
The principles of velocity
All else being equal, velocity has the largest impact on kinetic
energy; however, velocity cannot be examined in a vacuum, as at
suboptimal levels, expanding projectiles do not expand, and at
excessive velocity, projectiles lose their stability in flight. The
terms ‘‘high velocity’’ and ‘‘low velocity,’’ as they relate to
projectiles, can also be somewhat misleading. Consensus
between US and European research does not occur in the liter-
ature, with varying definitions correlating with where the study
was performed (Tables 4e6). The US literature designates high
velocity as being between 2000 and 3000 feet per second
(610e914 m/s), whereas studies from the United Kingdom
designate the line between low-velocity and high-velocity
projectiles as being 1100 feet per second (335 m/s), which is the
speed of sound in air. The earliest recognized entry of high-
velocity projectiles having an association with increased
wounding potential occurred during the Vietnam War. In 1967,
Rich reported in the Journal of the American Medical Associa-
tion that bullets fired from the M16 rifle inflicted tremendous
tissue destruction and injuries upon enemy combatants. The
muzzle velocity of the projectile shot from the M16 was 3100 feet
per second. When coupled with erroneous information published
by Rybeck in 1974 and in the 1975 edition of the Emergency War
Surgery manual regarding the size of the temporary cavity
caused by the missile, this information led to the common
misperception that high-velocity projectiles caused more
significant injuries. Part of the confusion regarding the wounding
potential of high-velocity projectiles is caused by misinterpre-
tation of ballistic gelatin model studies. Ballistic gelatin is 10% to
20% gelatin refrigerated to 4
to 10
C and is used as the tissue
model for ballistic studies. The wound-profile diagrams included
in this article and others represent the findings of these studies.
The validity of the ballistic gelatin model has been confirmed
by comparison with human autopsies, although there is confu-
sion in correlating these studies to living patients, because the
human body is much more resistant to deformation than gelatin
The effects of skin resistance, clothing, and opposition to

Table 2 Mechanisms of blast injury

Category Characteristics Body Part Affected Types of Injuries
Primary Unique to high-order explosives (HE), Gas-filled structures are most Pulmonary barotrauma (blast lung)
resulting from impact of the susceptible (lungs, middle ear, Tympanic membrane rupture
overpressurization wave with body and gastrointestinal tract) Abdominal hemorrhage and perforation
surfaces Globe rupture
Traumatic brain injury (TBI)
Secondary Results from flying debris and bomb Any Penetrating ballistic injury caused by
fragments shrapnel or fragmentation
Blunt injuries
Globe penetration (can be occult)
Tertiary Results from individuals being thrown Any Fractures
by the blast wind Traumatic amputation
Open/closed TBI
Quaternary All blast/explosion-related injuries/ Any Burns
illnesses/diseases not related to other Crush injuries
mechanisms (includes exacerbations or Open/closed TBI
complications associated with existing Asthma/chronic obstructive pulmonary
diseases) disease/Angina/Hypertension/
Hyperglycemia
Characteristics of Ballistic and Blast Injuries 21

separation of the fascial planes cannot be replicated in gelatin.

Table 3 Overview of improvised explosive device/blast-
Harvey evaluated the 2 types of pressure waves produced by
related injuries to the craniomaxillofacial region
penetrating objects in 1947: the sonic pressure wave and the
System Injury or Condition temporary cavity. The first wave is the sonic pressure wave,
Auditory Tympanic membrane rupture sometimes referred to as the ‘‘shock wave,’’ and it relates the
Ossicular disruption sound of the projectile striking the target. This wave transmits at
Cochlear damage the speed of sound (ie, approximately 4750 feet per second
Foreign body entrapment [1450 m/s]) and is traveling considerably faster than the
Eye/Orbit/Face Perforated/Penetrated globe projectile entering the target. No temporary cavity is formed
Foreign body entrapment with the sonic pressure wave, and in that regard it is analogous to
Air embolism the lithotripsy devices used for renal calculi destruction, with
Fractures corresponding minimal risks for tissue injury. Although American
Thermal injury and Swedish researchers have tried to disprove Harvey’s
Soft tissue disruption conclusions, no definitive evidence suggests that his findings are
Respiratory Blast Lung: direct consequence of the high- in error, and additional studies by French and American
order explosive overpressurization wave. researchers support the original findings of 1947.
The most common fatal primary blast injury The secondary pressure wave, referred to as the temporary
among initial survivors cavity, is formed when the penetrating projectile strikes tissue
Hemothorax and the wave radiates away laterally away from the permanent
Aspiration pneumonitis cavity of the projectile path. After being struck by the projec-
Airway thermal injury tile, the ballistic gelatin/tissue displays an obvious temporary
Pulmonary contusion/hemorrhage cavity, which potentially injures tissues, such as muscle,
CNS Injury Open/closed traumatic brain injury vessels, and organs. The clinical significance of this cavity is
Cerebrovascular accident variable, with no real consensus in the literature, and the
Spinal cord injury temporary cavity caused by the M16 in animal laboratory models
Air embolismeinduced injuries is much smaller than the approximate 18-cm temporary cavity
seen in ballistic gelatin. Dog models indicated that acute tissue

Table 4 Ballistic table for common handgun cartridges

Cartridge Velocity (fps)dmuzzle Velocity (fps)d100 yd Energy (fpe)dmuzzle Energy (fpe)d100 yd
0.25 900 742 63 43
0.32 1000 834 133 96
0.38 800 735 199 168
9 mm 975 899 310 264
0.357 Magnum 1500 1153 624 298
0.44 Magnum 1500 1196 999 635
0.45 970 860 386 304
0.50 Magnum 1700 1289 2246 1291

Table 5 Ballistic table for common rifle/machine gun cartridges

Cartridge Velocity (fps)dmuzzle Velocity (fps)d100 yd Energy (fpe)dmuzzle Energy (fpe)d100 yd
0.22 Hornet 3070 2246 732 392
0.243 3010 2744 1911 1588
0.270 3060 2851 2702 2345
0.30e30 2390 1959 1902 1278
0.30e06 2960 2750 3209 2769
5.56 mm (NATO) 2910 2675 1410 1192
7.62 mm (AK 47) 2360 2060 1521 1159
9-mm Parabellum (Uzi) 1060 946 338 268
0.50 BMG Sniper 2820 2732 13421 12428
Abbreviations: fpe, foot-pounds of energy; fps, feet per second.

Table 6 Ballistic table for common shotgun slugs

Cartridge (2.75-in. shell) Velocity (fps)dmuzzle Velocity (fps)d100 yd Energy (fpe)dmuzzle Energy (fpe)d100 yd
12-gauge (1-oz slug) 1560 977 2364 927
16-gauge (0.9-oz slug) 1590 975 2320 875
20-gauge (0.87-oz slug) 1590 975 2080 780
 A
7.62 mm NATO
Vel - 2830 f/s (862 m/s)
Wt - 150 gr (9.7 gm) FMC

Permanent Cavity

Temporary Cavity

0 cm 5 10 15 20 25 30 35 40 45 50 55 60 64

Fig. 8 (A) Ballistic representation of NATO 7.62-mm round fired from M16 rifle. Observe the relatively consistent permanent cavity and
laterally radiating temporary cavity, which begins to develop at approximately 20 cm into the tissue as the projectile begins to tumble.
This chart represents the projectile not striking any hard structures causing deformation or alteration in trajectory. The anatomic
characteristics of the head and neck do not have more than 20 cm of soft tissue present before encountering the bony skeleton, which
would have a clinical significance with regard to the temporary cavity should the projectile be of a trajectory to encounter only soft tissue
and miss the underlying facial bones. (B) Ballistic representation of a 7.52-mm soft point (SP) round striking muscle and bone. Note as the
projectile strikes the underlying structures, there is a tremendous increase in the permanent cavity, as well as the temporary cavity, as the
projectile deforms and fragments because of the soft tip construction. This deformation in the structural characteristic of the projectile,
and associated increase in the permanent and temporary cavities, greatly enhances the wounding potential of this round. (C) Ballistic
representation of a 22-caliber (5.6-mm) full-metal case (FMC) round striking bone and muscle. Note as the relatively small caliber
projectile strikes the underlying structures, there is a tremendous increase in the permanent cavity and associated temporary cavity as the
projectile deforms and continues on a new trajectory. This representation illustrates the wounding potential of a smaller caliber weapon
should the projectile actually strike the target and engage in energy transfer to the tissues. (From Emergency War Surgery. 3rd US
Revision. Washington, DC: US Government Printing Office; 2004.)
Characteristics of Ballistic and Blast Injuries
injury secondary to temporary cavity formation sustained with
high-velocity projectile strikes were no more than 5 cm and
were able to resolve within 72 hours. The US military conducted
extensive research into the wounding patterns of projectiles,
and the results are summarized in Fig. 8. The unique anatomic
differences of the craniomaxillofacial skeleton, a relatively thin
soft tissue layer overlying a dense foundation of bone, mitigate
some of the expected responses of the temporary tissue stretch,
as the overall thickness of the soft tissue envelope is generally
less than the required total distance needing to be traveled
before exhibiting secondary cavitation. Although sequential
soft tissue necrosis and small-vessel damage can occur, it is
much more likely to be in response to the exaggerated perma-
nent cavity of the projectile, which is greatly enhanced after
striking the underlying facial skeleton. The key point of under-
standing in the management of ballistic injuries is the perma-
nent cavity, which involves all of the tissues that are pushed
aside or destroyed during the flight of the projectile, and is the
location of the extent of the initial, or immediate, damage. A
projectile striking bone may cause fragmentation of the bullet
and/or native bone, forming numerous secondary missiles, each
capable of producing additional wounds, dramatically increasing
the size of the permanent cavity (Fig. 9). The size and shape of
the permanent cavity are determined by the density and
anatomic characteristics of the tissue lying in the projectile’s
path, the velocity of the projectile, the shape/characteristics
of the projectile, and likely most importantly the degree of
deformation of the missile as it travels through the tissues.
Characteristics of ballistic injuries
Gunshot injuries have been categorized in the literature as
penetrating, perforating, or avulsive. Penetrating wounds are
caused by the projectile striking the victim but not exiting the
body. The perforating injuries have entrance and exit wounds,
classically described as being without appreciable tissue loss.
Avulsive injuries have entrance and exit wounds, generally
presenting with an acute loss of tissue associated with the
passage of the projectile out of the victim. The type of firearm
used has implications in the wounding potential of the projec-
tile. As referenced earlier in this article, traditional concepts of
ballistics teach that impact kinetic energy is equal to one-half
the mass of the projectile times velocity squared (KE Z ½ MV2),
the increased energy transmitted from a high-velocity projectile
does not necessarily translate to increased wounding capacity.
Fig. 9 Example of a projectile striking the mandible, causing
fragmentation of the bone with the formation of numerous secondary
projectiles, which enlarged the size of the permanent cavity.
23
Cunningham and others suggest modifications need be used
to correct the kinetic energy estimate of wounding potential for
the type of tissue being struck by the projectile. Cunningham’s
belief was that softer tissues, such as brain and muscle, should
be associated with a lower exponent of injury (0.5) than harder
tissues, such as bone, which would have a higher exponent
(2.5) and therefore higher likelihood of permanent injury. The
corrected formula for estimating wounding capacity by kinetic
energy should be KE Z ½ MV0.5 to KE Z ½ MV2.5.
The soft tissue injuries inherent in ballistic trauma may
exhibit avulsive loss, sequential necrosis over days to weeks,
and compromised vascularity negating, or delaying, potential
microvascular or pedicled soft tissue reconstruction. Because
of the frequent occurrence of comminuted bony fractures, the
necessity for open reduction of the hard tissue injuries further
complicates the soft tissue healing response. A compromised
soft tissue bed can lead to necrosis of free-floating bone
fragments, avascular necrosis of the underlying facial skeleton,
devitalization of stabilized fracture segments, and develop-
ment of soft tissue infection or osteomyelitis, resulting in
increased tissue loss and scarring of the facial composite. Hard
tissue loss, including both bone and teeth, present the unique
challenges of reconstruction, including reconstitution of the
masticatory complex to support the oral intake of nutrition,
reestablishment of the normal anterior-posterior projection
and angular shape of the facial skeleton, maintenance of lip
competence, and control of salivation. Beyond the anatomic
concerns of reconstruction, the presence of specialized
vascular and neurosensory components in the maxillofacial
region, including the great vessels of the neck, the various
branches of the cranial nerves compromising both motor and
sensory functions, such as sight, smell, hearing, and taste, only
serve to further complicate the potential for catastrophic
injury, and lifelong deformity, that ballistic injuries cause to
the craniomaxillofacial region.
Summary
Ballistic injury wounds are formed by variable interrelated
factors, such as the nature of the tissue, the compositional
makeup of the bullet, distance to the target, and the velocity,
shape, and mass of the of the projectile. This complex arrange-
ment, with the ultimate outcome dependent on each other,
makes the prediction of wounding potential difficult to assess. As
the facial features are the component of the body most involved
in a patient’s personality and interaction with society, preserva-
tion of form, cosmesis, and functional outcome should remain the
primary goals in the management of ballistic injury. A logical,
sequential analysis of the injury patterns to the facial complex is
an absolutely necessary component for the treatment of cranio-
maxillofacial ballistic injuries. Fortunately, these skill sets should
be well honed in all craniomaxillofacial surgeons through their
exposure to generalized trauma, orthognathic, oncologic, and
cosmetic surgery patients. Identification of injured tissues,
understanding the functional limitations of these injuries, and
preservation of both hard and soft tissues minimizing the need for
tissue replacement are paramount.
Further readings
Barach E, Tomlanovich M, Nowak R. Ballistics: a pathophysiologic
examination of the wounding mechanisms of firearms. Part I. J
Trauma 1986;26:225.
24
Barnes FC. Cartridges of the world: a complete and illustrated refer-
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Clark N, Birely B, Manson PN, et al. High-energy ballistic and avulsive
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Powers & Delo
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