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Characteristics of Ballistic and Blast Injuries
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.
injuries to the head and neck region occur within relatively container packaging the projectile, propellant (gunpowder or
short distances, well within the effective range of the weapon cordite), and primer as a single unit for placement into the firing
and projectiles, these definitions and concepts have minimal to mechanism of the weapon. The propellant, such as gunpowder or
no correlation to the remainder of this article, or for the cordite, is the accelerant that actually allows for expulsion of the
surgical management of these ballistic injuries. projectile from the weapon. The more propellant in a cartridge,
as is seen in magnum and rifle rounds, the greater velocity the
Components of ballistic missiles projectile exhibits. Wadding, or wads, are generally plastic
frameworks with a paper or felt insert that hold the various
As previously described, the cartridge or round describes a unit pellets (projectiles) together in relation to the propellant,
of firearm ammunition. Each round consists of the following allowing for accurate and safe release of all the projectiles
(Fig. 2): simultaneously from the barrel in scattershot and shotgun
cartridges. Without the presence of wadding, the gas produced
Projectile by the propellant would push through the pellets, and not propel
Casing them as a unit. The primer is the only portion of the bullet with an
Propellant explosive charge. As the primer is struck by the firing pin of the
Primer weapon, the explosive charge is activated, igniting the propel-
lant and sending the projectile on its flight. Some cartridges are
The components of a round provide a basic understanding of referred to as rimfire, as the priming mechanism is contained
the principles of firearm injury. The projectile is the portion of within the rim of the base rather than a separate primer in the
the bullet that is expelled and strikes the target. The composi- center of the base. Generally, rimfire cartridges are less powerful
tional makeup of the projectile (soft lead, hollow point, full and cannot be reloaded, whereas centerfire cartridges can have
copper covering, or multiple pellets, as seen in shotguns) has the primer replaced and reloaded with another projectile.
a direct correlation on the wounding potential of the weapon. As Rifles, handguns, and machine guns have rifled barrels;
a projectile deforms after striking the victim, either as a result of essentially, spiral grooves cut into the length of the interior of the
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
YAW
manufacturers and firearm enthusiast. The casing is the
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 17
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 damage. For rifles and handguns, the practical clinical difference
injury occurs from a distance longer than 7 yards; type II injury is in whether the weapon was 10 feet, 100 feet, or 1000 feet away
sustained when the discharge is within 3 to 7 yards; type III injury from the patient otherwise has no bearing on surgical and
is within 3 yards. Type III injuries usually sustain dramatic soft and medical treatment.
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 Components of improvised explosive devices
discharge, Glezer and colleagues revised this classification
system and directed their attention to the size of the pellet The current conflicts in the Middle East have introduced a “new”
scatter. Type I injuries occur when pellet scatter is within an area mechanism for delivery of maxillofacial missile projectiles,
of 25 cm2; type II injuries are within 10 cm2 to 25 cm2; type III resulting in gruesome and avulsive craniomaxillofacial injuries,
injuries have pellet scatter less than 10 cm2. Although the Glezer the improvised explosive device (IED). Although not a new entity,
classification originally was developed for abdominal injuries, as the concept of IEDs has been deployed by guerilla forces since
the information is transferable to other areas of the body, and World War II, the description and media interest in the IED
determinations of tissue injury can be correlated directly to the warrants a brief discussion of its characteristic properties.
size of the pellet scatter. Intuitively, the closer the shotgun is to Explosives are broadly classified as low-order explosives (LE,
the patient, the more dramatic is the hard and soft tissue 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- proximity of the victim to the site of the explosion, the greater
tionally, explosives are categorized as manufactured, which the exposure to the shock wave energy. The initial shock wave
implies military-grade mass production and quality control, or of very high overpressurization, which is referred to as the
improvised. An IED is a bomb fabricated in an “improvised” primary, or “blast wave”, is unique to the HE and is followed
manner designed to destroy or incapacitate military personnel or closely by a “secondary wind,” a huge volume of displaced air
civilians. The bomb itself may be a conventional military-grade flooding back into the area, again under pressure. It is these
weapon, or an assortment of explosive components, such as sudden and extreme differences in pressures, and associated
gasoline, or agricultural fertilizer, as seen in the Oklahoma City
bombing of 1995. An IED has 5 components (Fig. 6):
Switch (activator)
Initiator (fuse)
Container (body)
Charge (explosive)
Power source (battery)
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 wounding potential occurred during the Vietnam War. In 1967,
neurologic, skeletal, or soft tissue injury (Fig. 7, Tables 2 and 3). 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
The principles of velocity muzzle velocity of the projectile shot from the M16 was 3100 feet
per second. When coupled with erroneous information published
All else being equal, velocity has the largest impact on kinetic by Rybeck in 1974 and in the 1975 edition of the Emergency War
energy; however, velocity cannot be examined in a vacuum, as at Surgery manual regarding the size of the temporary cavity
suboptimal levels, expanding projectiles do not expand, and at caused by the missile, this information led to the common
excessive velocity, projectiles lose their stability in flight. The misperception that high-velocity projectiles caused more
terms ‘‘high velocity’’ and ‘‘low velocity,’’ as they relate to significant injuries. Part of the confusion regarding the wounding
projectiles, can also be somewhat misleading. Consensus potential of high-velocity projectiles is caused by misinterpre-
between US and European research does not occur in the liter- tation of ballistic gelatin model studies. Ballistic gelatin is 10% to
ature, with varying definitions correlating with where the study 20% gelatin refrigerated to 4 to 10 C and is used as the tissue
was performed (Tables 4e6). The US literature designates high model for ballistic studies. The wound-profile diagrams included
velocity as being between 2000 and 3000 feet per second in this article and others represent the findings of these studies.
(610e914 m/s), whereas studies from the United Kingdom The validity of the ballistic gelatin model has been confirmed
designate the line between low-velocity and high-velocity by comparison with human autopsies, although there is confu-
projectiles as being 1100 feet per second (335 m/s), which is the sion in correlating these studies to living patients, because the
speed of sound in air. The earliest recognized entry of high- human body is much more resistant to deformation than gelatin
velocity projectiles having an association with increased The effects of skin resistance, clothing, and opposition to
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 23
injury secondary to temporary cavity formation sustained with Cunningham and others suggest modifications need be used
high-velocity projectile strikes were no more than 5 cm and to correct the kinetic energy estimate of wounding potential for
were able to resolve within 72 hours. The US military conducted the type of tissue being struck by the projectile. Cunningham’s
extensive research into the wounding patterns of projectiles, belief was that softer tissues, such as brain and muscle, should
and the results are summarized in Fig. 8. The unique anatomic be associated with a lower exponent of injury (0.5) than harder
differences of the craniomaxillofacial skeleton, a relatively thin tissues, such as bone, which would have a higher exponent
soft tissue layer overlying a dense foundation of bone, mitigate (2.5) and therefore higher likelihood of permanent injury. The
some of the expected responses of the temporary tissue stretch, corrected formula for estimating wounding capacity by kinetic
as the overall thickness of the soft tissue envelope is generally energy should be KE Z ½ MV0.5 to KE Z ½ MV2.5.
less than the required total distance needing to be traveled The soft tissue injuries inherent in ballistic trauma may
before exhibiting secondary cavitation. Although sequential exhibit avulsive loss, sequential necrosis over days to weeks,
soft tissue necrosis and small-vessel damage can occur, it is and compromised vascularity negating, or delaying, potential
much more likely to be in response to the exaggerated perma- microvascular or pedicled soft tissue reconstruction. Because
nent cavity of the projectile, which is greatly enhanced after of the frequent occurrence of comminuted bony fractures, the
striking the underlying facial skeleton. The key point of under- necessity for open reduction of the hard tissue injuries further
standing in the management of ballistic injuries is the perma- complicates the soft tissue healing response. A compromised
nent cavity, which involves all of the tissues that are pushed soft tissue bed can lead to necrosis of free-floating bone
aside or destroyed during the flight of the projectile, and is the fragments, avascular necrosis of the underlying facial skeleton,
location of the extent of the initial, or immediate, damage. A devitalization of stabilized fracture segments, and develop-
projectile striking bone may cause fragmentation of the bullet ment of soft tissue infection or osteomyelitis, resulting in
and/or native bone, forming numerous secondary missiles, each increased tissue loss and scarring of the facial composite. Hard
capable of producing additional wounds, dramatically increasing tissue loss, including both bone and teeth, present the unique
the size of the permanent cavity (Fig. 9). The size and shape of challenges of reconstruction, including reconstitution of the
the permanent cavity are determined by the density and masticatory complex to support the oral intake of nutrition,
anatomic characteristics of the tissue lying in the projectile’s reestablishment of the normal anterior-posterior projection
path, the velocity of the projectile, the shape/characteristics and angular shape of the facial skeleton, maintenance of lip
of the projectile, and likely most importantly the degree of competence, and control of salivation. Beyond the anatomic
deformation of the missile as it travels through the tissues. concerns of reconstruction, the presence of specialized
vascular and neurosensory components in the maxillofacial
Characteristics of ballistic injuries 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
Gunshot injuries have been categorized in the literature as
serve to further complicate the potential for catastrophic
penetrating, perforating, or avulsive. Penetrating wounds are
injury, and lifelong deformity, that ballistic injuries cause to
caused by the projectile striking the victim but not exiting the
the craniomaxillofacial region.
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 Summary
presenting with an acute loss of tissue associated with the
passage of the projectile out of the victim. The type of firearm Ballistic injury wounds are formed by variable interrelated
used has implications in the wounding potential of the projec- factors, such as the nature of the tissue, the compositional
tile. As referenced earlier in this article, traditional concepts of makeup of the bullet, distance to the target, and the velocity,
ballistics teach that impact kinetic energy is equal to one-half shape, and mass of the of the projectile. This complex arrange-
the mass of the projectile times velocity squared (KE Z ½ MV2), ment, with the ultimate outcome dependent on each other,
the increased energy transmitted from a high-velocity projectile makes the prediction of wounding potential difficult to assess. As
does not necessarily translate to increased wounding capacity. 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
Fig. 9 Example of a projectile striking the mandible, causing Barach E, Tomlanovich M, Nowak R. Ballistics: a pathophysiologic
fragmentation of the bone with the formation of numerous secondary examination of the wounding mechanisms of firearms. Part I. J
projectiles, which enlarged the size of the permanent cavity. Trauma 1986;26:225.
24 Powers & Delo
Barnes FC. Cartridges of the world: a complete and illustrated refer- Ordog GJ, Wasserberger J, Balasubramanium S. Wound ballistics:
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Inc; 2009. Powers DB, Will MJ, Bourgeois SL, et al. Maxillofacial trauma treatment
Clark N, Birely B, Manson PN, et al. High-energy ballistic and avulsive protocol. Oral Maxillofac Surg Clin North Am 2005;17:341e55.
facial injuries: classification, patterns, and an algorithm for primary Rich NM, Johnson EV, Dimond Jr FC. Wounding power of missiles used in
reconstruction. Plast Reconstr Surg 1996;98(4):583e601. the Republic of Vietnam. JAMA 1967;199:157e61.
Cunningham LL, Haug RH, Ford J. Firearm injuries to the maxillofacial Robertson BC, Manson PN. High-energy ballistic and avulsive injuries:
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pathophysiology and management. J Oral Maxillofac Surg 2003;61: 1999;79(6):1489e502.
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