Gunshot injuries involving the head and neck region yield profound morbidity and mortality rates. Projectile-related factors comprising various physical and dynamic properties of a bullet, as well as tissue-related factors, determine the disruptive effects of projectiles on living tissues. We experienced an extremely unusual case of a gunshot injury to the neck, wherein the bullet transversely penetrated across the deep neck structures to the contralateral side of the shoulder without damaging any vital organs. A 51-year-old man presented with a gunshot wound to the neck from a point-blank range. A bullet entry hole was observed on the left side of the neck without an exit hole; however, the patient was conscious, vital signs were normal, and no active bleeding, cranial nerve palsy, or aero-digestive tract injury was found. Imaging tests revealed a bullet lying in front of the right humeral head, which was extracted by emergency surgery. The patient was uneventfully discharged. According to the localization of the damaged tissues and the positional relationship between the bullet’s entrance and its destination, the bullet was estimated to have nonlinearly traversed the neck by traveling through the interstructural spaces associated with the least tissue resistance. Our experience strongly suggests the importance of realizing the unpredictable nature of a bullet trajectory in a body. An appropriate understanding of various ballistic factors and wounding mechanisms can be of great help in the adequate assessment and management of patients with gunshot injuries.

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Background Gunshot injuries involving the head and neck region yield profound morbidity and mortality rates because of the region’s dense structure occupied with essential organs. Both projectile- and tissue-related factors determine the disruptive effects of projectiles on living tissues, with the former comprising various physical and dynamic properties of a bullet. Although a bullet generally passes straight through the body, we experienced an unusual case of a gunshot injury to the neck, wherein the bullet penetrated through the deep structures to the contralateral side of the shoulder without damaging any vital organs, allowing us to discuss the diagnostic implications of wound ballistics in managing gunshot wounds with unexpected bullet trajectories. Case presentation A 51-year-old man presented with a gunshot wound to the neck from a point-blank range shooting during a local gang conflict. On admission, a bullet entry hole was observed on the left side of the neck without an exit hole; however, the patient was conscious; vital signs were normal; and no active bleeding, cranial nerve palsy, or aero-digestive tract injury were found. Imaging tests revealed a bullet lying in front of the right humeral head, a comminuted fracture of the right clavicle, and soft tissue edema and small air sacs among the deep neck structures, including the retropharyngeal space. Emergency surgery was performed to extract the bullet, which turned out to be a full metal-jacketed bullet. Five days later, the patient was uneventfully discharged. According to the localization of the damaged tissues and the positional relationship between the bullet’s entrance and its destination, we estimated that the bullet nonlinearly penetrated the neck through the interstructural spaces associated with the least tissue resistance, almost transversely, during its intra-body movement. Conclusion Our experience strongly suggests the importance of realizing the unpredictable nature of a bullet trajectory in a body. Awareness of various ballistic factors and wounding mechanisms, which affect a bullet trajectory and the magnitude of tissue damage, can be of great help in adequate assessment and management of patients with gunshot injuries.