Feature Article, April 2002

This month's feature article comes from Brandon Bertolli, who is researching gunshot wounds in South Africa.  Most of this research will be conducted in the adult trauma unit of the Johannesburg Hospital, Johannesburg, South Africa.  This is Mr. Bertolli's second submission and I would like to thank him for taking the time to submit these interesting case studies to firearmsID.com!

Adult Trauma Unit-Case Studies
Johannesburg, South Africa                   

The following gunshot injuries were encountered by Brandon Bertolli in 1999 at the Johannesburg Hospital in South Africa. They are examples of unexpected X-ray findings, or findings which did not match the clinical picture.

Case 1:                             

A 35 year old man was carjacked and forced to ride along with his assailants. He was beaten, shot twice then thrown out of the moving vehicle on to the highway. He was brought to hospital with a gunshot wound to the abdomen and to the leg. His condition was critical. A supine abdominal X-ray was done in the resuscitation bay:

The abdominal wound was a very small hole on the anterior left side of the abdomen, marked with a paperclip. A small bullet can be seen in the pelvis. It is typical of a bullet to "point" to the entrance wound, provided it has not been deflected or deformed. This happens because the bullet's centre of gravity is towards its base, and it may tumble base-first as soon as it loses its gyroscopic stability which it gained from the rifling of the barrel.

The patient's blood pressure could not be stabilized and despite every effort, he died. We were all very surprised that this little bullet had penetrated so deeply, obviously rupturing a major blood vessel.

I later placed one of my .25 cartridges over the bullet shadow on the film and the bullet in my cartridge matched the outline of the bullet on film exactly. This does not prove that a .25 was used, but indicates that no caliber larger than .25 was used. We cannot use X-rays to measure caliber precisely because all X-ray images are magnified to some degree. However, we can exclude calibers in situations such as this. The bullet shadow on X-ray film represents the largest caliber that the bullet can possibly be.

 

Case 2:                           

A young man sustained a gunshot wound to the left foot. There was a single skin breach over the first metatarsal, but no other breach could be found. As part of the standard projectile tracking protocol, a paperclip was taped to the patient's foot to mark the skin breach for X-ray. Here's what we found on the first view, the AP:

The first metatarsal is fractured and the paperclip overlies the fracture. No obvious metallic density can be seen in the vicinity of the fracture and no bullet can be seen on this view. So where did the bullet go? The lateral view of the foot reveals the bullet:

The paperclip fell off before the X-ray was taken, so I've marked where the skin breach was (E). The bullet entered the foot dorsally, fractured the first metatarsal then veered posterior and lodged beneath the heel. This demonstrates how bullets need not follow a straight path, especially after hitting bone.

 

Case 3:                          

An infant, around two years of age, was brought to hospital by his parents who claimed he had been struck by a stray bullet that had entered their apartment through a window. Upon removing his nappy (diaper) prior to X-ray, I found a loose fired FMJ bullet and a small breach in the skin on the right hip. I assumed that the bullet that I found in the nappy was the same bullet that had given the child the small skin beach. I now had to weigh up all the options. You must have good reason to X-ray a child's pelvis, as the young reproductive organs are especially prone to damage from ionizing radiation (X-rays).

I reasoned that there was the slight possibility that the bullet had penetrated deeply enough to cause a bone injury, then bounced back out of the wound. I also had to take in to account the extra variable of the elasticized nappy. I decided to do the X-ray, but remembered not to use a lead shield over the gonads since this was a gunshot pelvis and you should not use lead for that, since it may hide a bullet. Imagine my surprise when I saw this film:

A second bullet! Before doing another view (extra radiation) I checked the child's perineal area and crease of the buttocks for another loose bullet, but found nothing. I did this lateral (side) view of the pelvis to localize the bullet:

These two views proved that the bullet was lodged in the child's scrotum. I was puzzled by the bullet that I had found lying loose in the nappy - how did it get there? There was only one skin wound on the child. When I asked the parents how many shots they had heard, they became curt and unhelpful. I did not press the matter, just reported my findings to the casualty doctor. He should have found the loose bullet when he examined the child. This case proves that an entrance wound need not be the same size as the bullet, and one cannot assume that a recovered bullet belongs to a particular wound, without X-ray confirmation. It also underlines the rule that no gonad shielding must be used in gunshot wounds of the pelvis. If I had used lead shielding, I would have missed the bullet.

 

Case 4:                          

An obese man was shot in the chest by a carjacker. Upon arrival at hospital, the patient was stable and fully co-operative. An AP erect chest film was obtained:

Two metallic bodies can be seen, of two different densities. The person who X-rayed this man did not use paperclips, and when I went to speak to the patient, he had a very large dressing on the right side of his chest. Unfortunately I could not see where the entrance wound was. Nevertheless the evidence is plain to see. This is a core-jacket separation. A novice hospital worker may mistake it for two separate projectiles. The jacket appears as a less dense, sharp-edged folded density while the core, being lead, is very dense and less likely to form sharp edges and angles even if it is deformed.

The patient was fit enough to stand for a lateral view of the chest. Here is a magnified portion of that view:

Note the difference in densities between the core and the jacket. Usually the core will penetrate the target more deeply than the jacket. A special consideration in South Africa, with the high incidence of HIV infection in the population, is the risk of being cut by a detached jacket in surgery. The surgeon needs to be especially careful with jackets in the operating field. If a surgeon can retrieve the jacket for forensic analysis, he should use plastic forceps to prevent adding tool marks to the evidence.

 

Case 5:                                    

A middle-aged man was sitting in a parked truck with the engine turned off. A carjacker appeared at the side window and ordered the man out. The man refused to get out and instead started the engine, whereupon the gunman immediately opened fire. Because the vehicle was a truck, the victim was sitting higher than the level of the hijacker's head. So the gunman had to aim up if he wanted to shoot the victim in the head. Fortunately for the victim, the gunman was not accurate and hit him in the right acromion (shoulder) area. Perhaps the error of parallax played a role here, too. The bullet was deflected up from the shoulder into the frontal sinus region of the head; more specifically just lateral to the frontal sinus. The hijacker fled without firing any more shots.
The victim arrived at the hospital fully co-operative and stable.

The bullet was palpable under the patient's skin and it was decided to do skull X-rays to determine its exact location. The reason was that if he did not have a fracture and if his frontal sinus was not involved, then he could be kept for observation and avoid having a CT scan of his brain.These are the views, which were obtained:

Cars are right-hand drive in South Africa. The victim was facing the gunman at the time of the shooting, looking at him over his right shoulder. This explains how he sustained this unusual wound. On X-ray you can see that all the opacities are of the same density and that there are metallic specks near the bullet. If you look at the bullet outline carefully on the lateral view you'll notice that it fits the semi-wadcutter profile.

The films were shown to the neurosurgeon. He was not happy with the position of the bullet, since it could not be proven whether it had breached the sinus or not. A CT scan was ordered:

On this bone window slice you can see that the bullet has caused a frontal bone fracture and there is now a wound channel from the skin to the frontal sinus. This represents a significant infection risk. The decision was taken to debride the wound and keep the patient in for observation and make sure he did not develop an infection. Note that the CT scan gives the false impression that the bullet is a hollow point. This is an artifact. The bullet was solid lead. No intracranial hematomas were demonstrated on the brain window slices.

The patient's shoulder was X-rayed but nothing unusual was discovered. We could not find any other metallic densities in his clothing. The bullet was definitely all-lead. Considering it is an all-lead semi-wadcutter, it is most probably a bullet fired from a revolver.

The patient made a full recovery.

If anyone has any questions about X-Rays or raytracing (or anything really), you can contact me at bbertolli@yahoo.com.

All images seen on this page are copyright 2002 Brandon Bertolli.  All rights reserved.


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