Retained Projectile. A bullet from a remote gunshot wound to the right chest migrated to the skin surface over time and was removed at the patient’s request. The bullet (insert) was sent to pathology. (Photo contributor: Lawrence B. Stack, MD.)
Gunshot injuries can be accurately identified and classified as entrance, atypical entrance, exit, or atypical (grazing) wounds based on their physical characteristics. Wounds are not classified based on their size. Physical findings in and around these wounds may offer evidence as to the actual mechanism of injury, supporting or refuting the initial history given to the provider. As most physical findings are transient in nature (cleaned, debrided, or eventually healed), the emergency physician must be diligent in recognizing and documenting them at the time of presentation. The physician’s failure to accurately document the physical characteristics of the wounds or correctly interpret the physical findings can compromise the legal process and obstruct justice.
Gunshot wounds of entrance are divided into four categories based on their range of fire: distant, intermediate, close, and contact. Range-of-fire is the distance from the gun’s muzzle to the victim’s skin or clothing.
The size of the entrance wound bears no relation to the caliber of the inflicting bullet. Entrance wounds over elastic tissue will contract around the tissue defect and have a diameter much less than the caliber of the bullet.
Distant Wounds: The distant wound is inflicted from a range sufficiently distant that the bullet is the only component expelled from the muzzle that reaches the skin. There is no visible tattooing or soot deposition associated with a distant entrance wound. As the bullet penetrates the skin, friction between it and the epithelium results in the creation of an “abrasion collar” (Fig. 19.1). The width of the abrasion collar will vary with the angle of impact. Elongated abrasion collars from projectiles that enter on an angle may produce a collar with a “comet tail” (Fig. 19.2). Most entrance wounds will have an abrasion collar; however, gunshot wounds to the palms and soles are exceptions—their entrance wounds appear slit-like. Bullets that pass through an intermediate object, a door or windshield for example, will become deformed or misshapen (Fig. 19.3). A misshapen bullet creates an irregular abrasion collar (Fig. 19.4) as compared to the smooth abrasion collar created by a nondeformed bullet (Fig. 19.1).
Distant Gunshot Wound. An abrasion collar surrounds the wound defect and is created from the friction of a bullet passing through the skin. All entrance wounds will have an abrasion collar with the exception of entrance wounds to the palms and soles. The lack of soot, seared skin, or gunpowder tattooing confirms this is a “distant” range ...