Retained Bullet Removal in Civilian Pelvis and Extremity Gunshot Injuries: A Systematic Review

Abstract

Background Although gunshot injuries are relatively common, there is little consensus about whether retained bullets or bullet fragments should be removed routinely or only in selected circumstances. Questions/purposes We performed a systematic review of the literature to answer the following questions: (1) Is bullet and/or bullet fragment removal from gunshot injuries to the pelvis or extremities routinely indicated? And, if not, (2) what are the selected indications for removal of bullets and/or bullet fragments? Methods A search of the English-language literature on the topic of gunshot injury and bullet removal was performed using the National Library of Medicine and MEDLINE 1 and supplemented by hand searching of bibliographies of included references. Studies were included if they provided clinical data on one or both of our study questions; included studies were evaluated using the levels of evidence rubric. Most studies on the subject were expert opinion (Level V evidence), and these were excluded; one Level III study and seven Level IV studies were included.Results No studies provided a rationale for routine bullet removal in all cases. The studies identified bullet fragment removal as indicated acutely for those located within a joint, the palm, or the sole. Chronic infection, persistent pain at the bullet site, and lead intoxication were reported as late indications for bullet removal. Conclusions The evidence base for making clinical recommendations on the topic of bullet and bullet fragment removal after gunshot injury is weak. Level I and II evidence is needed to determine the indications for bullet removal after gunshot injury.

Lasting impression of violence: Retained bullets and depressive symptoms

“…Retained bullets are common after firearm injury but few reports have described their impact on survivors. While current literature indicates that retained bullets should be removed for particular physiologic indications [3–14], to our knowledge, the current report is the first study to suggest a psychological benefit to having no retained bullets. The most important finding of our study is that the presence of a retained bullet was associated with more severe depressive symptoms in Black men who sustained firearm injuries.…”

“…Often a bullet will be excised if an apparent medical benefit (e.g. treating injury-site chronic pain or preventing lead toxicity) [14], but there is a paucity of data regarding the psychological consequences of retained bullets to date. The removal of the retained bullet for any such non-physiologic reason depends on patient and surgeon agreement given a patient’s risk profile, without any universal, standard or evidence-based guidelines.…”

Migrating bullet from thorax to retroperitoneum

“…There are controversies about bullet removal indications. Based on a systematic review conducted by Riehl et al, [6] in case of asymptomatic patients, it is common to accept bullets as inert harmless metallic bodies and avoid bullet removal. Meanwhile, an asymptomatic bullet should be followed for a while, because as reported by Yenigün et al, [7] a retained bullet in the lung may cause bronchiectasis even after more than 20 years.…”

Gunshot-Related Injuries to the Foot & Ankle: Review Article

“…Similar to the hand, projectiles may be located where they can cause discomfort or mechanical problems, such as the sole or the dorsum of the foot, and should be removed. Additionally, it is recommended to remove bullets when they are in a joint due to the potential mechanical trauma with subsequent arthritis and loss of function, and bullet lead toxicity can damage the cartilage 14,46,50 (Figure 3).…”