There are two questions in case of acute bullet injuries: Is hot bullet sterile? and What are the indication for removal of bullet that has done no vital damage?

1. Hot bullet is sterile: This is found to be false by various articles [1,2,3,4]. Bullets can cause infection by two mechanisms; by carrying skin and associated flora with it [5] and by puncturing internal organs that have native bacterial flora like gut [6]. However this is not an indication of exploration and removal of bullet. Antibiotics have shown to effectively control this infection thus making the bullet an inert foreign body [exceptions noted below].

2. What are the indications of removal of bullet: In  general,  missiles  retained  in  the  soft  tissues  or  muscles  of  the  axial  and  appendicular  skeleton  become  encased  in  a fibrous,  avascular  scar (7). As  a result,  they essentially  become  inert  and  are  shielded  from  their host.  It  has been  demonstrated  that  excellent  long-term results  can therefore  be achieved  without  the  routine  removal  of  these  missiles  [10].  The  risk  of  infection  is low (2-3%),  and  the  risk  of  dissolution  of  the  bullet  with  local  or  systemic  lead  toxicity  is  extremely  rare[7].

The risk of lead poisoning is seen in places where bullet is continuously bathed in fluid like in joints, near CSF or in a pseudo cyst [11-22]. Intraarticular bullet fragments cause synovitis as lead can be dissolved by synovial fluid [13] and can cause accelerated osteoarthritis [lead arthropathy] [16,17,18,22]. Rare complication like squamous cell carcinoma is reported around retained bullet [23]. A very interesting case report mentioned elevated serum lead levels during pregnancy in a woman with retained bullet in spine [what may be the cause of this accelerated lead dissolution during pregnancy?]. This caused elevated serum lead levels in the newborn and multiple congenital abnormalities [24,25 (incidentally these two reports are duplicate publication, where the same patient was published by the authors in two different journals and two years apart with significant changes in the authors list!]. Thus this may again be a relative indication of removal of bullet in a young female who wishes to conceive.

Thus generally retained bullet fragments are benign [7], and the surgeon should not try to remove them all. However, sometimes fragments maybe located in areas that will cause pain, such as around joints, or in the subcutaneous tissues. These fragments may be removed electively after the acute injury has healed [4]. Also from review of all articles [1-29] I could identify few indications for removal of Bullets

1. Bullet close to a joint

2. Bullets in hand or feet

3. When bullets can be felt below the skin (radiological assessment of depth is erroneous). Many a times, when treated conservatively the bullets will be pushed out towards the skin where they are palpable and then can be removed easily

4. Probably bullet lodged in intra discal area in spine

5. In spine if the bullet is responsible for secondary neurological problems or infection it should be removed [4]. Again bullet removal is debatable here in spine cases [9], however bullets in contact with CSF or spinal cord need to be removed [10]

6. Bullets lying close to major vessels may cause late aneurysms and may be an indication of removal once the acute injury has subsided [relative indication]

7. When bullet is located near nerve structures and there is irritation of the nerve with progressive neurologic signs or symptoms

8. Females who wish to conceive [24]

9. When easily accessible through the wound J

10. A relatively new reason for bullet removal is the clinical indication for a magnetic resonance imaging (MRI) study. This examination cannot be safely performed on patients with retained shrapnel because patients who undergo MRI examination may suffer from magnetic effects on the shrapnel (eg, pain, bruises, injury to nerves or blood vessels in the vicinity of the shrapnel). Thus, shrapnel removal is indicated before performing an MRI study [29].

Few more points that I came across during this review

1. Any joint that is affected in bullet injury has to be opened and thoroughly debrided and checked for bullet fragments

2. Bullet lodged in bone can be observed and do not require removal unless they are intraarticular or are lodged in the bone travelling through a joint causing a fistulous synovial tract between the joint and the bullet as reported by Worland [26 ]. This also alerts us to look at the tract through which bullet has travelled in the body and correlate.

3. Nonviable muscle, especially in an anaerobic environment, is ideal pabulum for the growth of many types of bacteria, especially clostridia. After a gunshot wound, the number of aerobes in devitalized muscle has been observed to be 10,000 organisms per gram of tissue at 6 hours and 100,000 at 12 to 24 hours, with the quantity of anaerobes at 6 hours falling within this range. Therefore, debridement optimally is done within 6 to 8 hours of injury. However, this timing is inexact because of the degree of tissue destruction, the presence of shock, and host resistance [27].

4. Wounds are not to be closed primarily [28]

3. Vascular embolisation of bullets is reported [and also migration into the portal system, pericardial space, spinal cord, kidneys, ureters, urethra, and lungs has been observed rarely [27].

I have tried to read as many full articles as possible to reach logical conclusions as above, however this should not be considered as a systematic review but as a general review on the topic


Ashok Shyam

Head of IORG



1. F.P. Thoresby, H.M. Darlow. The mechanisms of primary infection of bullet wounds. Br J Surg, 54 (5) (1967), pp. 359–361

2. F.P. Thoresby, J.C. Watts. Gas gangrene of the high-velocity missile wound. Br J Surg, 54 (1) (1967), pp. 25–29

3. A.W. Wolf, D.R. Benson, H. Shoji et al. Autosterilization in low-velocity bullets. J Trauma, 18 (1) (1978), p. 63

4. Volgas DA, Stannard JP, Alonso JE. Current orthopaedic treatment of ballistic  injuries. Injury. 2005 Mar;36(3):380-6.

5. Grosse Perdekamp M, Kneubuehl BP, Serr A, Vennemann B, Pollak S. Gunshot-related transport of micro-organisms from the skin of the entrance region into the bullet path. Int J Legal Med. 2006 Sep;120(5):257-64.

6. Sarmiento JM, Yugueros P, Garcia AF, Wolff BG. Bullets and their role in sepsis after colon wounds. World J Surg. 1997 Jul-Aug;21(6):648-52.

7. J.M. Rhee, R. Martin. The management of retained bullets in the limbs. Injury, 28 (Suppl 3) (1997), pp. S-C23–S-C28

8. Lichte P, Oberbeck R, Binnebösel M, Wildenauer R, Pape HC, Kobbe P. A civilian perspective on ballistic trauma and gunshot injuries. Scand J Trauma Resusc Emerg Med. 2010 Jun 17;18:35

9. Waters RL, Adkins RH. The effects of removal of bullet fragments retained in the spinal canal. A collaborative study by the National Spinal Cord Injury Model  Systems. Spine (Phila Pa 1976). 1991 Aug;16(8):934-9.

10. Howland  WS,  Ritchey  SJ.  Gunshot  fractures  in  civilian  practice.  An  evaluation  of  the  results  of  limited  surgical  treatment.  J .  Bone  Joint  Surg.  1971;53A:47-55.

11. Grogan  DE’, Bucholz  RW.   Acute  lead  intoxication  from  a  bullet  in  an  intervertebral  disc  space:  Case  Report.  J .  Bone  Joint  Surg.  1981;63A:1180-1182.

12.  Stromberg  BV  Symptomatic  lead  toxicity  secondary  to  re-  tained  shotgun  pellets:  Case  Report.  J .  Trauma  1990;30:356- 357.

13.  Leonard  MH.   The  solution  of  lead  by  synovial  fluid.  Clin.  Orthop.  1969;64:255-261.

14.  Linden MA,  Manton  WI ,   Stewart  RM,   Thal  ER,  Feit  H.   Lead  poisoning  from  retained  bullets:  Pathogenesis,  Diagnosis,  and  Management.  Ann.  Surg.  1982;195:305-313.

15.  Janzen  DL,  Tirman  PFJ,  Rabassa  AE,  Kumar  S. Lead  ‘bursogram’  and  focal  synovitis  secondary  to  a  retained  intraarticular  bullet  fragment.  Skel.  Radiol.  1995;24:142-144.

16.  Peh  WCC,   Reinus  WR.   Lead  arthropathy:  a  cause  of  delayed  onset  lead  poisoning.  Skel.  Radio].  1995;24:357-360.

17.  Primm  DD.   Lead  arthropathy  -  progressive  destruction of  a  joint  by  a  retained  bullet:  Case  Report.  J .  Bone  Joint Surg.  1984;66A:292-294.

18. Goldman  A,  Minkoff  J ,  Price  A,  Krinick  R.   A  posterior  arthroscopic  approach  to  bullet  extraction  from  the  hip. J .  Trauma  1987;27:1294-1300.

18.  Switz  DM,   Elmorshidy  ME,  Deyerle  WM.   Bullets,  joints,  and  lead  intoxication:  A  remarkable  and  instructive  case.  Arch.  Intern.  Med.  1976;136:939-941.

19.  Viegas  SF,  Calhoun  JH.   Lead  poisoning  from  a  gunshot wound  to  the  hand.  J .  Hand  Surg.  1986;11A:729-732.

20.  Watson  N,   Songcharoen  GP.  Lead  synovitis  in  the  hand:  A  Case  Report.  J .  Hand  Surg.  1985;108:423-424.

21.  Windler  EC,  Smith  RB,  Bryan  WJ ,  Woods  GW.  Lead  intoxication  and  traumatic  arthritis  of  the  hip  secondary  to  retained  bullet  fragments.  J .  Bone  Joint  Surg.  1978;60A:254- 255.

22.  Sclafani  SJA,  Vuletin  JC,   Twersky  J .   Lead  arthropathy:  Arthritis  caused  by  retained  intra-articular  bullets.  Radi-  ology  1985;156:299-302.

23.  Philip  J .  Squamous  cell  carcinoma  arising  at  the  site  of  an  underlying  bullet.  J .   Royal  Coll.  Surg.  Edinburgh  1982;27:365-366.

24. Raymond LW, Ford MD, Porter WG, Saxe JS, Ullrich CG. Maternal-fetal lead poisoning from a 15-year-old bullet. J Matern Fetal Neonatal Med. 2002 Jan;11(1):63-6.

25. Porter S, Hanley E, Sing RF. Fetal anomalies resulting from maternal bullet-related plumbism. J Trauma. 2004 Jun;56(6):1353-5.

26.  Worland  RL.  Bone  c y s t   following  gunshot  wound:  Case  Report.  J .  Trauma  1975;15:613-615.

27. Bartlett CS. Clinical update: gunshot wound ballistics. Clin Orthop Relat Res. 2003 Mar;(408):28-57.

28. Ficke JR, Pollak AN. Extremity War Injuries: Development of Clinical Treatment Principles. J Am Acad Orthop Surg. 2007 Oct;15(10):590-5.

29. Peyser A, Khoury A, Liebergall M. Shrapnel management. J Am Acad Orthop Surg.  2006;14(10 Spec No.):S66-70.

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