Guns are highly effective in inflicting pain and trauma to one’s enemy in the blink of an eye. Therefore, the wounds formed as a result of bullet injuries are categorized as gunshot wounds, while the study of these injuries is called wound ballistics.

These wounds are rising due to the increasing vices and gun availability rates. According to the World Population Review, the United States had the 2nd highest incidence of gun deaths in 2019. Firearm (gun) injuries pose a serious health problem in the US. With an economic burden of more than 70 billion dollars annually, the healthcare system is choked by this category of injuries.

A 2017 study investigating the geo-demographics of gunshot wounds found a high prevalence of firearm-related injuries in young black males. Additionally, it was revealed in a wound ballistic study that the most common anatomic site for gunshot wounds is the extremities. It also concluded that soft tissue injuries are highly prevalent, and non-surgical management of such wounds was effective.

However, studies have shown that morbidity and mortality increase significantly if two or more gunshot wounds are present that have caused multiple organ injuries. 

Nature Of Gunshot Wounds

Before explaining why your surgeon does not want to extract the bullet, let us look at the nature of a gunshot wound. First, forensic pathologists have to work hard to study ballistics. This is because gunshot wounds are complex in nature, and a lot of trauma is involved.

The object causing the injury (shrapnel or bullet) is the projectile. Projectiles from different weapons have distinct patterns of entering the body. For example, the entry injury obtained from a rifled firearm has a unique marking.

Identifying the path taken by the projectile (bullet, metal fragment, birdshot) is crucial in planning the treatment and estimating the prognosis. Certain factors are critical in planning the ideal treatment, including:

• Weapon type
• Use of rifled or smooth-bore firearms
• Distance of fire
• Entry and exit wound

These factors are also crucial in determining whether to extract or keep the penetrated bullet.

Factors In Favor Of Keeping The Bullet Inside The Body

There are many hindrances in removing a bullet from a patient’s body. Various sensitive organs and regions of the body make surgery a complicated and complex process. Therefore, extraction and excavation can be more dangerous than keeping them inside. The following is a list of reasons why keeping a bullet might be a good idea:

1.     Bullets Are Inert

Most bullets and metal fragments are inert. This, however, does not mean that the lead in the pellets is biocompatible and can be completely safe if left inside. Bullets lodged in the limbs cause no significant harm (apart from the entry injury), and infections from bullet injuries are rare; therefore, keeping them inside is OK. This might be because the heat sustained by the bullet during the shooting process somewhat causes the metal sterilization.

In the latest 2021 study, 344 patients with retained bullet fragments after nonfatal gunshots were analyzed. It was noted that only 11% of people reported retained bullet fragments (RBF)-related complications (infection, pain, fracture non-union, and bone erosion).

2.   No Significant Benefit Of Removal

According to a study, bullet removal of 90 patients with bullets (or fragments) in the spinal canal showed no significant benefit of removing the bullet. Despite 20% of cases having perforations of the alimentary canal, there were no reports of infection. Plus, removing the bullets did not positively impact the motor recovery.

Bullets can easily fracture bones and get lodged in the affected bone. However, they do not impact the bone reformation process. As per a study published in 2015, retained bullets do not interfere with a bone reunion. In this particular study, a mere 3% of the patients developed non-reunion and required revision surgery.

3.    Unfavorable To Remove The Fragments

In most cases, the surgeon decides to keep the retained bullet untouched. This is because that might be unfavorable for the patient. Shrapnels from a blast/explosive are tiny fragments easily lodged in the body. These shrapnels are small and rarely cause complications if retained; however, removing them might involve a hectic procedure that might be risky for the patient.

Removing bullets from the spine might require extensive spine surgery with a risk of post-surgical complications. Even the equation for abdominal bullets favors risks retaining the bullet rather than putting the patient through a risky ordeal. This claim is backed by research that suggests that bullets should be kept in the spinal and intra-abdominal regions.

Surgeons weigh the risks vs. harms of certain of not doing a particular procedure before making a decision. For example, retained bullets cause more damage on removal than on retention. Most cases in emergency care are stabilized and managed but not favored for bullet removal.

Indications For Bullet Removal

There are certain conditions in which the surgeon will extract the retained bullet. The indications for removing a bullet are discussed below:

1.     Bullet Inside Cerebrospinal Fluid/Joint/Globe Of Eye

In a case study, a 42-year-old male was hit by multiple bullets retained in his spinal cord. However, six years later, the patient reported having low back pain and had to be treated using laminectomy. The leading cause of this complication was lead poisoning. Therefore, it is indicated to remove a bullet from the cerebrospinal fluid (CSF).

In another study published in the Indian Journal of Orthopaedics, a person suffered from a retained bullet in the joint, and the late arthroscopic retrieval of the bullet led to immediate pain relief and weight-bearing.

The Globe of the eye is another sensitive area from which a bullet should be removed following a gunshot injury. Though rare, bullets breaching the antrum and sinuses must also be removed.

2.   Fragments/Bullets Impinging A Nerve

Shrapnels, metal fragments from a ballistic explosion, should be removed if they are impinging a nerve or a nerve root. Nerve impingement can have grave consequences, including nervous symptoms such as pain, numbness, burning, and tingling sensations.

Astonishingly, gunshot injury has also resulted in Bell’s palsy too. Therefore, it is favorable to remove any bullet putting pressure on a nerve.

3.    Bullets Inside A Vessel

Your surgeon will opt to remove the bullet if the fragment has lodged inside the vessel’s lumen. Bullet embolization is rare due to a retained projectile in the vessel. A 29-year-old man reported pseudoaneurysm (in the thoracic aortic region) after a gunshot incident. Thus, removing bullets from arterial or venous lumen is a must.

Similarly, if a bullet increases the risk of ischemia or embolization, it should be removed. These indications are also followed by European trauma surgeons.

Harms Of Keeping A Bullet Inside

1. Lead Burden

Perhaps the most significant harm or side effect of retained bullets inside the body is increased lead burden. Lead is a poisonous metal that has negative impacts on the body. The retention of a projectile (bullet, metal fragment) is believed to increase the lead levels in the blood. As per a study, retained lead bullets significantly increased the body’s lead burden.

2. Lead poisoning

Modern research indicates that retained bullets can cause severe conditions such as lead poisoning and toxicity. This toxicity can even prove to be fatal if it goes unnoticed.

It is suggested that bullets and other intraconal foreign bodies be removed promptly if indicated.

A detailed study concludes that bullet lodgment can cause sufficient lead poisoning, which presents itself in the following ways:

• Unexplained abdominal pain
• Joint pains
• Neurological disorders
• Motor nerve symptoms of the extremities (motor neuropathy)
• Burton line (dark lines between gums and teeth)

A systematic review and meta-analysis suggest that patients with multiple retained bullet fragments are at a very high risk of having elevated blood lead levels. Therefore, pieces should be removed as soon as possible to prevent the worsening of the injury.

Bottom Line

Firearm injuries are becoming increasingly common nowadays. The high incidence of gunshot wounds adds to the economic burden of the healthcare budget. A gunshot wound is complex, and wounds differ based on the distance of the shot, type of weapon used (muzzle, rifle), and region of the body involved. Most patients having bullets lodged in the body are advised by surgeons to retain them. This is because bullets are inert and rarely cause infection. There has been no significant benefit of removing bullets on recovery, and the risk of complication is more in removing than keeping. However, if a bullet gets lodged in the CSF, joints, eye globe, the lumen of a vessel, impinges a nerve, and increases chances of ischemia/embolization, it should be removed.