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Ballistic injury is associated with bullet velocity and mass, as well as other bullet and tissue characteristics.1–3 Slow-moving bullets crush more tissue, and fast-moving bullets cause more cavitation. Bullet mass, which is related to diameter and length, largely determines how deeply the bullet will penetrate tissue. Bullet construction (such as whether the bullet is solid lead with no bullet jacket, is partially jacketed, or has a full metal jacket) largely determines if the bullet will deform or fragment. Bullet shape and center of mass (which determine how soon it will yaw in its path through tissue), the thickness of the body part wounded (determining whether the bullet has a long enough path through tissue to deform or yaw; Figure 263.1-1), tissue type struck (e.g., femur vs. lung), tissue elasticity, density, and internal cohesiveness [which determine how well the tissue will withstand tissue stretch (temporary cavitation) forces] are all important factors in determining the nature of the wound produced. The amount of kinetic energy “deposited” in a victim wounded by a projectile is not a reliable predictor of wound severity.4

Figure 263.1-1.

Compare two .22 caliber bullets. A. A .22 long-rifle round (left) and an M16 round (right). B,C. Wound profiles in ballistic gelatin of the same .22 long-rifle (B) and .224 caliber M-193 round of the M16A1 rifle (C). [Full metal case (FMC) is a synonym for full metal jacket, the type of bullet used in the military.] This figure shows that caliber (bullet diameter in decimals of an inch or in millimeters) is only one indicator of wounding potential and not a very good one. Because of much higher velocity [3094 ft/s (943 m/s), as opposed to 1122 ft/s (342 m/s) for the .22 long-rifle bullet], because it fragments in tissue, and because of greater bullet mass, the M16 bullet has the potential to cause a much more severe wound if the anatomic part struck is sufficiently thick. Note that in the gelatin block, both the permanent cavity and the temporary cavity caused by the M16 bullet are much larger than those of the .22 long-rifle bullet. As is usual for a nondeforming bullet, the temporary and permanent cavities caused by the .22 long-rifle bullet are largest when the bullet is at 90 degrees of yaw.

An understanding of wound ballistics enables physicians to evaluate and treat missile wounds effectively. Based on common misconceptions about wound ballistics, some authors have suggested unnecessary and possibly harmful treatment for gunshot wounds. An example of such a harmful recommendation is that for mandatory surgical excision of the tissue surrounding the path of the projectile through tissue whenever an extremity wound is caused by ...

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