Introduction to Gunshot Injury Rehabilitation

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Top Contributors - Ewa Jaraczewska and Jess Bell  

Definition of the Gunshot Injury

Gunshot injury is "the penetrating injury and its related consequences caused by a projectile from a firearm."

Firearms and Gunshot Injuries

Low Velocity Firearms

• Muzzle velocity less than 1200 feet
• Include small handguns and pistols
• Cause Gustilo-Anderson type I and type II injuries
  • Type I
    • Low energy
    • Wound size less than one centimetre
    • Minimal soft tissue damage and fracture comminution
    • Wound is clean
    • No neuromuscular injury
  • Type II

shotgun is technically defined as low velocity, yet this device inflicts devastating wounds when fired at close range due to high-energy transfer

firearms with a muzzle velocity greater than 2000 ft/s (commonly rifle calibers) and are associated with more substantial tissue damage

Physical impairments and Complications

"Gunshot injuries commonly result in diffuse soft-tissue damage, volumetric muscle loss, hemorrhage, fracture, and severe pain"

"The main mechanisms underlying penetrating ballistic tissue wounds associated with bullets include: (1) permanent cavitation, whereby tissue is destroyed by projectile compression and shearing that leaves a projectile trail; and (2) temporary cavitation, caused by tissue distention due to high-energy pressure vibrations from the projectile’s trail . Other issues, such as localised frictional heat stress, may exacerbate these primary insults. The extent of the firearm wound (i.e., depth and area damaged) is highly dependent upon projectile-tissue characteristics, whereby both the projectile (e.g., velocity, mass, shape, calibre, material, yawing and impact distance) and tissue impacted (e.g., density, elasticity, and thickness) interact to define the full extent and nature of injury. In general, skeletal muscle is suggested to be more sensitive to permanent cavitation, with temporary cavitation thought to induce less damage (unless the vasculature is disrupted) due to skeletal muscle’s inherent elasticity"

In regards to skeletal muscle impacted by a projectile or blast injury, damage is inflicted via various routes with laceration, contusion/crush injury, denervation (i.e., neural deficits), haemorrhage/ischaemia (i.e., vascular impediments) burns, and VML in particular of concern (Fig. ​(Fig.1).1). Both primary firearm or blast wounds can be aggravated by secondary trauma that further complicates severity of the injury, including development of infection/sepsis (caused in some cases by contamination with bullet/shotgun wadding, or other debris collected from clothing or skin), surgical debridement of damaged tissue (optimally performed within 6–8 h of trauma), and/or excessive physical movement.

Immobilisation, systemic inflammation, hyperglycaemia/insulin resistance, and nutrient deficiency are common side effects induced by ballistic trauma7, which are well-established mediators of muscle wasting in both the acute and chronic setting

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