HEALTH SCIENCE JOURNAL ® VOLUME 4, ISSUE 4 (2010)

Wound Ballistics: Analysis of Blunt and Penetrating Trauma

Mechanisms

Christina–Athanasia Alexandropoulou1, Elias Panagiotopoulos2

1. Undergraduate Student, Department of Nursing, Technological Educational Institute of Patras,

Patras, Greece.
2. Lecturer in Ballistics, Department of Mathematics and Science of Engineer, Hellenic Military
Academy, Vari, Attiki, Athens, Greece.

Abstract

Background: The tissue factors important in wound ballistics provide a useful insight into the
pathophysiology of organ injury in all traumas. Wound ballistics includes penetrating and blunt
trauma mechanisms. Although the mechanism of a traumatic event may be pure blunt or
penetrating trauma, the mechanism of tissue injury may be mixed.
The aim of the present study was to review the literature about Blunt and Penetrating Trauma
Mechanisms.
Method and Material: The method that was used for the realization of the research is the search
of articles, researches and papers to the internet (MEDLINE, EMBASE and CINAHL databases) in
order to become a review of the Hellenic and the foreign bibliography from 1988 until today.
Results: The varied ability of different types of tissue to tolerate the physical displacement of
tissue stretch in gunshot wounds and the inability of any tissue to survive being crushed by a
bullet is a model for the relative abilities of different tissues to tolerate blunt trauma and
penetrating trauma of all types. Center-fire rifle bullets crush tissue as they pass through it, as
does any penetrating trauma agent. This crushed tissue does not survive. Center-fire rifle bullets
also cause blunt trauma by tissue displacement (temporary cavitation). The ability of different
tissues to survive this blunt trauma is related primarily to tissue elasticity and cohesiveness.
Conclusions: The blunt and penetrating trauma aspects of wound ballistics can be used to explain
the response of all tissue to blunt and penetrating trauma of all types, assisting in predicting and
explaining the severity or lack of severity of tissue injury in trauma in general.

Keywords: blunt trauma, gunshot wounds, penetrating trauma, wound ballistics

Corresponding author:

Panagiotopoulos Elias
Department of Mathematics and Science of Engineer, Hellenic Military Academy,
Vari, Attiki, Athens
Tel: 0030 2610 991 177
E-mail: [email protected]

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Missile mass and velocity establish the

Introduction upper limit of the tissue damage a moving
bullet can cause: the bullet's wounding

I
n all penetrating trauma, tissue is crushed potential. Bullets of equal wounding
by the penetrating object. That tissue potential may produce wounds of very
does not survive. Similar to the effect of a different severity. The amount of wounding
bullet passing through tissue, if a penetrating potential actually used and the amount of
object other than a bullet is large enough or resulting tissue disruption depend on bullet
moving fast enough, some blunt trauma, due construction and the physical properties of
to displacement of tissue adjacent to the the tissue penetrated2. Whether the bullet
path of the penetrating object, will occur. has enough mass and velocity to reach the
This is identical to the type of blunt trauma depth of vital structures can determine final
occurring during temporary cavitation in outcome4.
certain gunshot wounds. The ability to Bullets crush the tissue and run into,
survive temporary cavitation blunt trauma is killing that tissue. The bullet may also cause
very specific. More elastic, more cohesive a splash in tissue, stretching tissue by
tissue, such as skeletal muscle, lung, empty displacement (temporary cavitation). This
intestine, nerve, blood vessel and to some may or may not damage tissue, depending on
extent bone, can tolerate this quite well. tissue type4.
Less elastic, less cohesive organs, such as Bullets with equal wounding potential
liver, brain and heart, do not tolerate often do not produce similar wounds. Even if
temporary cavitation blunt trauma well1. similar amounts of wounding potential are
In typical urban gunshot wounds, all of available, this potential may or may not be
the tissue injuries are caused by tissue used up in the wounded subject. If used, the
crushed by the bullet, its fragments or the same amount of wounding potential may be
secondary missiles it creates by breaking used as varying amounts of tissue crush and
apart the structures through, which it tissue stretch (temporary cavitation),
passes. Significant temporary cavitation is depending on the velocity, mass and
very uncommon in urban gunshot wounds, diameter of the bullet2. No matter how much
because the most are caused by less potent wounding potential is used, the severity of
handguns. A center-fire rifle or large the wound produced is very tissue
handgun is usually required to fire a bullet dependent. Tissue stretch will be tolerated
capable of causing significant temporary very differently by different tissues. A
cavitation2. heavier and slower bullet crushes more
Blunt trauma can be local, such as from tissue but induces less temporary cavitation,
being struck with a hammer or the local most of the wounding potential of a lighter,
blunt trauma of temporary cavitation faster bullet is likely to be used up forming a
associated with penetrating trauma. Blunt larger temporary cavity, but this bullet
trauma can be diffuse, such as that resulting leaves a smaller permanent cavity (crushes
from failing from a height or being an less tissue)4.
unrestrained passenger in a high-speed motor The physical properties of a tissue
vehicle accident. The tissues that tolerate through, which a missile passes (tissue
well the blunt trauma from tissue elasticity, density, cohesiveness, internal
displacement during temporary cavitation architecture), the diameter, shape, mass and
stretch also tolerate blunt trauma from other velocity of the projectile, whether it
causes well3. expands into a mushroom shape or breaks
and fragments, its internal construction, the
WOUND BALLISTICS length of the wound path and whether it is
sufficiently long to allow bullet deformation
Wounding potential or yaw to 90° are all primary determinants
of wounding2. A center-fire "high-velocity"

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rifle bullet, if it traverses only elastic tissue, height, then it is possible these two missiles
such as skeletal muscle, does not yaw of equal kinetic energy to sustain different
significantly, does not fragment or deform degrees of damage. The rubber ball behaves
and does not hit a major blood vessel or like skeletal muscle or lung and the raw egg
nerve. It usually causes a fairly minor wound. like brain or liver. The amount of kinetic
It will exit the extremity with most of its energy in tissue is not a good predictor of
wounding potential unspent. If this same wound severity. Collisions between bullets
bullet hits a large bone, fragments and does and tissue are not elastic and kinetic energy
not exit, it will crush a large volume of is not conserved. Most is lost as heat4, 5.
tissue, will create secondary missiles, such as An understanding of wound ballistics
bone fracture fragments, which also crush allows the physician to evaluate and treat
tissue and is likely to disrupt the missile wounds without repeating the errors
neurovascular integrity of the area wounded, of "conventional wisdom". Many papers have
expending all its wounding potential in the been printed suggesting harmful and
patient and usually producing a severe unnecessary treatment for gunshot wounds
wound. The amount of tissue crushed by a as a result of common misconceptions about
bullet depends on its size and shape and wound ballistics4. An example of such an
whether it deforms or fragments5. unnecessary and harmful recommendation is
If the tissue wounded is relatively elastic for mandatory surgical excision of the tissue
and cohesive, the amount of tissue crushed is surrounding the bullet path whenever an
the primary determinant of wounding2. All extremity wound is caused by a high-velocity
crushed tissue is killed. Tissue stretch bullet. Military and civilian experts have
(temporary cavitation) often has relatively taught that, such excision of the wound
little wounding effect in elastic cohesive path, to be important, because tissue
tissue, such as skeletal muscle or lung. If an exposed to temporary cavity formation rarely
organ is inelastic, near-water density and not survives and will become necrotic. Clinical
very cohesive, such as brain or liver, experience and research show this notion to
temporary cavitation can cause a severe be false, particularly in the case of extremity
wound5. wounds4. Experiments in wounding
Bullet penetration depth is directly mammalian animals with military rifle bullets
related to bullet mass and bullet velocity have been performed. An important feature
and inversely related to bullet diameter of these experiments is that a control group
(including the effect of increased diameter of animals was wounded, but not treated
from mushrooming). If a bullet lacks surgically. These experiments have disproved
sufficient mass or velocity or expands to such the assertion that all tissue exposed to
an extent that it uses up its wounding temporary cavitation does not survive. They
potential crushing superficial tissues and also show that in extremity wounds,
causing temporary cavitation stretch, it may complete excision of the bullet path and
not reach the depth of vital structures, such extensive debridement usually are not
as the heart. It will not hurt what it does not necessary. This finding corroborates many
reach4, 5. observations in humans with rifle bullet
It is wrong to think that one can predict wounds of the extremities. In addition, the
the wound produced according to whether a large exit wound produced by the M16 or AK-
bullet is "high velocity" or "low velocity." 47 military rifle bullet often creates its own
Bullet velocity is only one factor in wounding excellent wound drainage, which assists
and in some wounds it may be a minor healing5.
factor. Kinetic energy expended in elastic Intense local vasospasm after the
tissue may produce little damage, as tissue passage of a high velocity bullet lasts about 3
stretch may be well tolerated. If a rubber hours and often includes a substantial
ball and a raw egg of equal weight are amount of tissue around the permanent
dropped onto a cement floor from the same wound channel. If patients are operated on

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very soon after wounding, the extent of

apparently devitalized tissue will be
increased by this intense vasoconstriction Crushing of tissue
around the bullet path. The tissue, when A missile crushes the tissue it strikes,
examined at surgery, may have poor colour, thereby creating the permanent cavity. Yaw
bleeding, contractility and consistency. is the angle between the longitudinal axis of
These are the four C's, by which surgeons the bullet and its path of flight. If the bullet
sometimes decide whether tissue is viable. is traveling with its pointed end forward and
After a rifle bullet extremity wound, more its longitudinal axis parallel to the axis of
tissue often is viable than is apparent at the flight (0° yaw angle), it crushes a tube of
initial surgical examination6. After the initial tissue no greater than its diameter. When
period of vasoconstriction, a period of the bullet yaws to 90°, the entire
hyperemia follows. longitudinal axis of the bullet strikes the
tissue. The amount of tissue crushed may be
Mechanisms of wounding three times greater than at 0° yaw angle. If
Missiles are passing through tissue wound the bullet strikes an intermediate target,
by only two mechanisms. These are crush before striking the patient, the bullet may
and stretch. Tissue crush is the crushing of yaw, deform or decelerate. Its wounding
the tissue struck by the projectile (forming properties will be altered, sometimes
the permanent cavity). Tissue stretch refers increasing wound severity and other times
to the radial stretching of the projectile path decreasing it1, 7.
walls (during temporary cavity formation). When striking soft tissue with sufficient
The sonic pressure wave preceding the bullet velocity, soft point and hollow-point bullets
through tissue does not damage tissue2. are designed to deform at the tip into a
Both missile and tissue characteristics mushroom shape. This flattening of the
determine the nature of the wound. Bullet bullet tip increases the bullet's surface area
mass (which is related to bullet diameter and and the tube’s diameter of tissue crushed,
length) often determines whether the bullet decreasing the penetration depth. If the
will penetrate tissue to the depth of vital mushroomed diameter is 2.5 times greater
structures, bullet construction determines than the initial diameter of the bullet, the
whether the bullet will deform or fragment cross-sectional area of the tissue’s tube
and bullet shape and center of mass crushed by the bullet is 6.25 times greater
determine how soon it will yaw in its path than the amount that would have been
through tissue. If it does not deform into a crushed by the unreformed bullet. Thus, the
mushroom shape, the thickness of the body deformed bullet makes a larger diameter
part wounded determines whether the bullet hole (the permanent cavity) than would the
has a long enough path through tissue to original unexpanded bullet have made1, 7.
deform or yaw tissue type (e.g. femur, lung, Unjacketed lead bullets cannot be driven
liver). Also, it decides tissue elasticity, faster than 2000 ft/sec (610 m/sec), without
density, specific gravity and internal some of the lead stripping off in the barrel.
cohesiveness and determines how well the This barrel fouling is avoided, if a bullet
tissue will withstand temporary cavitation jacket made of a harder metal (such as
stretch. All of these characteristics are copper or a copper alloy) is used to surround
extremely important, in addition to bullet the lead. The jacket of a military bullet
velocity, in determining the nature of the completely covers the bullet tip (a full metal
wound produced. Wound classification - jacket or "ball" bullet). Full-metal-jacket
systems based on bullet kinetic energy or bullets either stay intact or break and
velocity markedly overemphasize the fragment when it is at 90° yaw angle. They
importance of velocity, in determining the do not deform into a mushroom shape7.
wound produced and largely ignore the other Civilians often use hollow-point or soft point
factors2, 6. bullets. Hollow-point bullets have a hole in

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the jacket at the bullet tip. Soft-point target, leading to the wounding of
bullets have some of the lead core of the bystanders9.
bullet exposed at the bullet tip. These Overexpansion can result in insufficient
constructions weaken the bullet tip, tissue penetration to reach and disrupt vital
flattening on impact (into a mushroom structures. Usually, a bullet penetration
shape). If it does not deform, a pointed depth of 12-20 inches (approximately 30-50
civilian bullet will behave like a full-metal- cm) is required to reliably reach and disrupt
jacket bullet, yawing at some point in its vital structures in humans. This depth is
path through tissue8. needed, because many bullets travel on an
If a bullet is partially or completely oblique course through the body, lengthening
jacketed, the bullet jacket usually cannot be the wound path to the center of the body.
distinguished from the lead core on standard Also, bullets often pass through other body
radiographs, as the entire bullet. If the parts, such as extremities, held up in front of
bullet has some lead exposed, it often loses the trunk for defense or offense. Possibly,
small flakes of lead along its path through the bullet must still be able to penetrate to
tissue, even if it does not break into large the body center and once there, have
fragments8. Sometimes, as the bullet enough wounding potential left to disrupt
deforms or breaks into fragments, the bullet the vital structures8, 9.
jacket separates from the bullet and is Bullets of the hollow-point or soft-point
visible on a radiograph. When a full-metal variety are more likely to fragment in tissue
jacket bullet yaws to 90° and if it breaks at than a full metal-jacket bullet, adding to
the cannelure (the circular groove in the tissue disruption. Because of bullet
bullet where it is crimped into the cartridge expansion into a mushroom shape and bullet
case), the bullet jacket may come off fragmentation, civilian hollow-point and
portions of the broken bullet, especially the soft-point bullets used in rifles and large
back half. When an unreformed bullet is seen handguns are usually more damaging to
on a radiograph, it is usually not possible to tissue than military full metal-jacket bullets
state accurately whether the bullet is fully fired from rounds otherwise configured
jacketed, without recovering the bullet3,8. identically4, 9.
Although soft-point and hollow-point Bullets are not sterilized by the heat of
bullets from center fire rifle rounds usually firing. They can carry bacteria from the body
expand into a mushroom shape in tissue, surface deep into the wound. They can also
many soft-point and hollow-point handgun spread bacteria from perforated organs (e.g.
bullets from various manufacturers fail to colon) along their entire tissue path10.
expand. This failure often occurs, because of
insufficient striking velocity, an excessively Stretching of tissue
thick or unbending bullet jacket construction Fired from an appropriate and well-
variability in manufacture of the bullet or designed firearm, a bullet flies in the air
occasionally, plugging of the tip of a hollow- with its nose pointed forward and it yaws
point bullet by material from an only 1° to 5°. It is stabilized in this point-
intermediate target, such as drywall or forward position by bullet spin imparted by
heavy clothing, through which the bullet the rifling (spiral grooves) in the gun barrel.
passed before penetrating the wounded Yaw occurs around the bullet's center of
subject. This lack of expansion is most likely mass. In pointed rifle bullets, the center of
with short-barreled handguns and those of mass is behind the midpoint of the bullet's
less potent calibers (e.g. 25 and 32), which longitudinal axis1.
have slower bullet velocity. Overall, about Although the bullet's spin is adequate to
one-third of soft-point and hollow-point stabilize gyroscopically against yaw in its
handgun bullets fail to expand in human soft flight through air, its spin is not adequate to
tissue. Lack of expansion can lead to stabilize it in a point-forward position in
disastrous results owing to perforation of the tissue, because of the higher density of

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tissue relative to the air. If it does not missiles. In only two cases, an organ that was
deform in tissue, a pointed bullet eventually not hit (but was within a few centimeters of
yaws to a base-forward position. This is true the projectile path) suffered some
for both an unreformed civilian bullet and an disruption. In the vast majority of gunshot
intact military full-metal-jacket bullet1. wounds, all tissue injured significantly, has
After the bullet deforms into a been crushed by the intact bullet, bullet
mushroom shape or if unreformed, yaws to fragments or secondary missiles (Fig. 1)12.
90°, crushing its maximal amount of tissue Near-water-density, less elastic tissue
(unless it breaks into fragments, which will (such as brain, liver or spleen), fluid-filled
crush more tissue owing to increased surface organs (including the heart, bladder or fluid-
area of the fragments compared to the intact filled intestine) and dense tissue (such as
bullet). It is slowed down rapidly, as its bone) may be damaged severely, when a
wounding potential is used up moving tissue large temporary cavity contacts them or
radially away from its path. This force forms within them. More elastic tissue (such
creates the temporary cavity4. as skeletal muscle) and lower-density elastic
Temporary cavitation is a splash in tissue (such as lung) are less affected by the
tissue: a bullet at 90° of yaw causes a much formation of a temporary cavity2, 12.
larger splash than one with little yaw2. This
is entirely analogous to the minimal splash a
diver makes with a good dive compared to
the large splash produced by a belly-flop. In
tissue, this splash and the temporary cavity
can produce injury from localized blunt
trauma if it is large enough to stretch the
tissue and displaces beyond its breaking
point. The maximal temporary cavity occurs
several milliseconds, after the bullet has
passed through the tissue3.
The temporary cavity caused by common
handgun bullets is generally too small to be a
significant wounding factor in all. Center-fire
rifle bullets and some large handgun bullets Figure 1: In typical urban gunshot
often induce the formation in tissue of a wounds, temporary cavitation blunt trauma
large temporary cavity 10-25 cm (4-10 plays no significant role in wounding. The
inches) in diameter. This can be a significant bullet, its fragments (if it breaks into pieces,
wounding factor, depending on the as here) and secondary missiles created by
characteristics of the tissue in which it the breaking up of structures the bullet
forms11. passes through crush tissue.
In general, the wounding effect of The effect of the passage of a bullet
temporary cavitation has been greatly through tissue
exaggerated in the literature, particularly Experiments with ballistic gelatin have
with regard to extremity wounds. Injuries of shown that the most rifle bullets with a full
vessels, bones, nerves and organs remote or metal jacket yaw significantly only at tissue
distant from the projectile path are depths greater than the diameter of human
commonly mentioned, but, in fact, are extremities. The wound profile technique
extremely rare12. A review of 1400 rifle can be used to study bullet soft tissue
wounds from Vietnam (the Wound Data and wounds13. This technique was developed at
Munitions Effectiveness Team study) found the Letterman Army Institute of Research to
no cases of bones being broken or major measure the amount, type and location of
vessels being torn that were not penetrated tissue disruption produced by a given
by the bullet, bullet fragments or secondary projectile. The entire missile path is

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captured in one or more blocks of 10% path. It is held in by a trampoline-like action

ballistic gelatin at 4°. This gelatin of the skin. Bullets can be caught below the
reproduces the penetration depth, projectile scalp or subcutaneously in the rest of the
deformation, fragmentation pattern, site of body16.
yaw, size and site of the permanent and When bullets penetrate thin portions of
temporary cavity produced by the missile in the skull, such as the squamous portion of
living swine muscle. Measurements are taken the temporal bone, characteristic beveling
from cut sections of the gelatin blocks after may not be evident. In those cases and
mapping of the fragmentation pattern with others, characteristic fracture patterns of
two x-ray views at 90°. These data are then the skull can sometimes be used to
reproduced on a wound profile diagram3. differentiate entrance and exit holes16. Skull
In the first 12 cm of a soft tissue wound fractures propagate across the calvarium
path (the average thickness of an adult faster than the bullet travels through the
human thigh), there often is little or no brain. Fractures radiating from the entrance
difference between the wounding effect of wound extend across the calvarium
low- and high- velocity bullets if the high- unimpeded. However, those radiating from
velocity bullet is of the military full-metal- the exit will stop when they meet a
jacket type14. This is particularly true of the previously made fracture radiating from the
relatively heavier military rifle bullets such entrance hole. This technique of analysis is
as those fired by the AK-47 and NATO 7.62 often used to determine the order of shots,
mm rifles. A wound of an extremity caused when there are multiple calvarial
by an AK-47 bullet, which does not hit bone, penetrations or perforations. Concentric
is often similar to a handgun bullet wound15. heaving fractures can occur in arcs between
If a high-velocity, heavy bullet does not the linear fractures radiating from the
deform, fragment or hit a bone it may exit entrance and exit holes, if sufficient
an extremity with much of its wounding temporary cavitation forces are generated in
potential unspent. These same bullets are the brain17.
often lethal in chest or abdominal wounds, Handgun wounds of the extremities yield
because the trunk is thicker than an characteristic fracture patterns. Frequently
extremity and allows the bullet a sufficiently seen, gunshot fractures include divot
long path through tissue to yaw10, 13. Maximal fractures of cortical bone, drill-hole
temporary cavitation induced by the full- fractures, butterfly fractures and double
metal-jacket AK-47 bullet usually occurs at a butterfly fractures. Divot fractures are the
tissue depth around 28 cm, much greater removal of a divot-hike portion of the edge
than the diameter of a human extremity. In of a bone, always involving the cortex and
fact, this depth is even greater than the occasionally some adjacent medullary bone.
diameter of the human torso from most Longitudinal fracture line(s) may extend
projections. This is why most torso wounds along the bone from the point of the divot
made by the AK-47, when firing the common fracture. Drill-hole fractures are
nondeforming military bullet, resemble characterized by a cylindrical core of bone
wounds made by much lower-velocity removed by the bullet, with a diameter
handgun bullets. Civilian soft-point or approximating the bullet's diameter on the
hollow-point rifle bullets deform soon after entrance side and usually a larger defect on
entering tissue and usually produce a much the exit side. Nondisplaced fracture lines
more severe extremity wound than do low- sometimes radiate from these defects. These
velocity handgun bullets15. usually heal well2, 17.
Because of the skin's toughness and Spiral fractures can extend proximal or
elastic properties, a bullet that might have distal to the site of bullet impact on bone.
the capacity to penetrate 10-12 cm (4-5 This type of gunshot fracture is especially
inches) farther in tissue often is arrested common in bones under torsional stress at
subcutaneously at the end of the wound the time of bullet impact. Torsional stress

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can result either from twisting of the from temporary cavitation stretch can be a
extremity or owing to the normal irregular reliable indicator of the amount of wounding
shape of some bones from biomechanical potential used to injure the extremity5, 18.
forces, when the bone is placed under load.
Torsion is always presented in a femur,
because the femoral head is eccentric in the
posterior view and is arched in the lateral
view18.
Especially interesting are the rare spiral
fractures that occur at variable distances
proximal or distal to the fracture at the site
of bullet passage. Sometimes there is a
considerable length of normal intervening
bone, particularly in the femur. These
remote fractures probably occur, because of
stress risers and the fact that the bone was
under load or stress at the time of impact.
This fracture has occasionally been
Figure 2: Τhe greater the comminution
attributed to a fall, which some patients
of a gunshot fracture, the more wounding
report after being wounded. The site, where
potential was used to cause it and the worse
the fracture occurs, is a function of the
the prognosis for the injured area. The
peak-moment location and the allowable
surface area of the bullet is greatly
residual torsion17, 18.
increased by breaking up into small
It is important to note the analogy
fragments. These fragments crush more
between the remote spiral femoral fracture
tissue and cause all the wounding potential
and the damage to aircraft structures
of the missile to be used up in the wounded
subjected to small arms fire. A rifle bullet
object. Bone fragments (secondary missiles)
striking at a highly oblique angle may not
also crush tissue. Comminuted gunshot
even penetrate a thin-walled metal
fractures have more complications, such as
structure, such as an airplane wing, and may
compartment syndrome, infection (cellulitis
cause far more damage than a 90° drill-hole-
and osteomyelitis), non union or delayed
type penetration. This is due in part to the
union.
stressed state of the structure and the wing-
skin properties. Wing-skin functions in a
manner similar to the cortex of a bone along
the diaphysis4.
In gunshot fractures from rifles and large
handguns, a greater extent of comminution
may be seen4. The magnitude of bone
fragmentation depends on the amount of
pressure generated within the bone.
Complications, such as wound infection,
osteomyelitis, compartment syndrome and
delayed union or non-union are more
frequent in highly comminuted gunshot
fractures, because of the soft tissue damage
(including macro- and micro-vascular
damage), caused by the bullet fragments and Figure 3: A penetrating object, whether
bone fragments as they crush tissue (Fig. it is a bullet, a knife, an ice pick, a nail or
2)5.The severity of fracture comminution and any other object, does not have to use a
the presence of air between muscle bundles great deal of wounding potential to cause a
serious wound. All it has to do is to pass

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through a vital structure. In this case, a train (blunt trauma), thrown through the air
small-caliber handgun bullet with little and impaled on a post (penetrating trauma)
16
wounding potential has caused a devastating .
injury by passing through the spinal cord. Both blunt and penetrating mechanisms
The effect on the patient of the trauma of organ injury can occur in blunt trauma,
sustained when bones fracture and their fragments
Wounding is like real estate. The most penetrate adjacent tissue (Fig. 4). The
important aspect is location. An ice pick stab pathophysiology intraperitoneal and
wound or a small-caliber bullet of low extraperitoneal bladder rupture is a model of
wounding potential, which passes through blunt and penetrating trauma in general.
the spinal cord or brain, can have a Extraperitoneal bladder rupture is more
devastating effect (Fig. 3)19. A bullet with a common (80-85% of bladder rupture cases),
great deal of wounding potential passing as blunt trauma is more common than
through the muscle of the thigh may cause a penetrating trauma16. It is usually caused by
minor wound. This makes the job of the blunt trauma causing pelvic fractures and
physician much easier. It is not important to bony spicules. Intraperitoneal bladder
know the details of what wounded the rupture (15-20% of bladder rupture cases) is
patient. The job of the physician is to the result of blunt trauma compression of a
examine the patient, to determine the full bladder, causing a sudden rise in
location and severity of the injuries and to intravesical pressure and rupturing the
initiate treatment. Imaging studies play an bladder dome2.
important role18, 19.
In penetrating trauma, the tissue is
crushed throughout the length of the hole.
That tissue does not survive. The effect
depends on what organ was injured and on
how completely it was injured19.
In blunt trauma, organs with inadequate
tissue cohesiveness to tolerate displacement
will fracture and tear. Often, multiple
bleeding points and injured surfaces are seen
(similar to the effect on the liver of
temporary cavitation stretch, a splash in
tissue). In gunshot wounds, the splash is
confined to a small area around the bullet
path. In an automobile accident or a fall, the Figure 4: Penetrating trauma can be a
amount of tissue volume affected by the feature of blunt trauma. This splenic
tissue splash is much greater and can laceration was caused by the displaced rib
sometimes be the entire body (such as with fracture fragments seen at the posterior left
whole-body-deceleration blunt trauma) 18. lateral margin of the spleen (arrows).
Trauma is frequently not purely blunt or Although the patient experienced blunt
purely penetrating. Impurity can result from trauma, the spleen experienced penetrating
the mechanism of injury or within blunt trauma by the rib fragments. This is
trauma from fracture fragments, clothing or analogous to the creation of secondary
adjacent objects penetrating tissue19. During missiles in gunshot wounds. In this case, the
blunt trauma, a pelvic fracture fragment, blunt trauma has created secondary missiles
which penetrates the bladder, causes a that have crushed tissue of the spleen,
penetrating injury of the bladder, even causing laceration and bleeding. The clot and
though the trauma mechanism is blunt. The serum layers surrounding the spleen, the
overall mechanism of injury may be impure, intrasplenic pseudoaneurysm with swirling
as in the case of a person who is hit by a blood of the same density as the intra-

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arterial and intravenous contrast medium often at vessel branch points, where the
and the moderate-size hemoperitoneum in vessel may be less mobile and therefore less
the subphrenic spaces and gastrohepatic able to tolerate displacement. Such vascular
ligament are noted. tears are uncommon, because of the
The bladder, like any organ, cannot elasticity and cohesiveness of vascular
remain uninjured after penetrating trauma tissue20.
(tissue crush). Bone fragments penetrate the For a given blood vessel, decreased
bladder causing extraperitoneal bladder blood pressure can be the result of systemic
rupture. Even if the amount of tissue crushed hypotension due to hemorrhage, local
is very small, when the integrity of an organ hypotension due to hemorrhage proximal to
is violated, organ function is often the point of blood pressure cuff placement
compromised. In this case, the bladder leaks. or intimal injury with partial thrombosis of
In contrast, in blunt pelvic trauma, the vessel’s lumen proximal to the point of
sometimes without pelvic fracture, blood pressure measurement21. It is
intraperitoneal bladder rupture occurs, when important to compare and contrast the
the bladder is full and the dome of the effect of bleeding into a big space (e.g. the
bladder cannot tolerate the tissue stretch, peritoneal cavity or pleural space) with the
caused by increased intravesical pressure effect of bleeding into a smaller contained
due to bladder compression. The bladder space (e.g. the epidural or subdural space or
dome tissue tears. Usually, the cohesive the intact pericardial space). In the former
tissue of the bladder dome (elastic, case, a large volume of blood can be lost
stretchable musculature and mucosa) from the vascular compartment, leading to
tolerates the tissue stretch due to the systemic hypoxia due to both diminished
increased intravesical pressure from blunt oxygen-carrying capacity and systemic
trauma and does not tear. Most automobile hypotension due to lost intravascular
accident patients with seat belt trauma to volume. When bleeding into a small,
the pelvis do not have intraperitoneal confined space, local organ compression can
bladder rupture or any bladder rupture1, 5. cause severe injury or death, such as from
Complete or partial vascular occlusion compression of the brain or heart. This organ
can occur, when intimal injury and dysfunction is unrelated to the systemic
intravascular thrombus result from effect of blood’s loss from the vascular
penetrating trauma or rarely, when tearing space. In this case, the blood is injuring by
of the vessel results from tissue its mass effect20, 21.
displacement (blunt trauma). Vascular
tearing from blunt trauma, when it occurs, is

Figure 5: Left: In patients in intestinal walls, accentuating the mucosal

hypovolemic shock, blood is shunted away pattern into spiculations. This has been
from the splanchnic circulation. This process previously described in pediatric patients as
sometimes leads to stasis and edema in part of the hypoperfusion complex. If the

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HEALTH SCIENCE JOURNAL ® VOLUME 4, ISSUE 4 (2010)

patient recovers hemodynamically, the CT management. Intestinal injury detected by

appearance reverts to normal within hours. CT, but not clinically apparent is particularly
Note that the inferior vena cava (IVC) is flat important and requires laparotomy21.
and the aorta is small. The IVC can be flat on
some scan slices in normal patients, but will
be of normal caliber on others. When it is Conclusion
consistently flat on every scan slice, think of
hypovolemia, particularly when the aorta The pathophysiology of organ injury in
and lilac arteries are also small. Right: penetrating trauma has been well studied for
Another example of shock bowel in a firearm injuries. Center-fire rifle bullets
different patient. Moderate-size crush tissue as they pass through it, as does
hemoperitoneum is seen in the paracolic any penetrating trauma agent. This crushed
gutters bilaterally, displacing the intestines tissue does not survive. Center-fire rifle
away from the flank stripes. The IVC and bullets also cause blunt trauma by tissue
aorta are more normal in caliber in this case displacement (temporary cavitation). The
than in the view at left. ability of different tissues to survive this
Imaging can be very helpful in patient blunt trauma is related primarily to tissue
management by demonstrating intestinal elasticity and cohesiveness. Which tissue will
injury, aortic injury, solid organ injury and be severely injured and which will survive
active bleeding and it sometimes can assist relatively intact can be fairly well predicted
in assessment of intravascular volume21. in gunshot wounds. This article proposes that
Computed tomography (CT) is particularly the already understood blunt and
useful. The lack of exsanguinating penetrating trauma aspects of wound
hemorrhage after a gunshot wound does not ballistics can be used to explain the response
rule out a through-and-through penetrating of all tissue to blunt and penetrating trauma
injury of the aorta. Conventional of all types, assisting in predicting and
angiography or CT is required for adequate explaining the severity or lack of severity of
assessment, if the bullet path is near to the ctissue injury in trauma in general.
aorta. Injuries to large veins are sometimes
treated by ligation (Fig. 5). This procedure
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