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J Am Acad Orthop Surg, Vol 14, No 10, September 2006, S66-S70. <BR>
© 2006 <A HREF="/misc/terms.dtl">the American Academy of Orthopaedic Surgeons</A>
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<H2>
Shrapnel Management
</H2>
<EM>
</NOBR><NOBR>Amos Peyser, MD</NOBR>,
<NOBR>Amal Khoury, MD</NOBR> and
<NOBR>Meir Liebergall, MD</NOBR>
</EM><P>
<A NAME=""><!-- null --></A>
Dr. Peyser is Head of the Orthopedic Hospitalization Unit, Department<SUP> </SUP>of Orthopedic Surgery, Hadassah University Hospital, Jerusalem,<SUP> </SUP>Israel. Dr. Khoury is Senior Orthopedic Surgeon, Department<SUP> </SUP>of Orthopedic Surgery, Hadassah University Hospital. Dr. Liebergall<SUP> </SUP>is Chairman, Department of Orthopedic Surgery, Hadassah University<SUP> </SUP>Hospital.<SUP> </SUP><P>
<A NAME=""><!-- null --></A>
None of the following authors or the departments with which<SUP> </SUP>they are affiliated has received anything of value from or owns<SUP> </SUP>stock in a commercial company or institution related directly<SUP> </SUP>or indirectly to the subject of this article: Dr. Peyser, Dr.<SUP> </SUP>Khoury, and Dr. Liebergall.<SUP> </SUP><P>
<A NAME="ABS"><!-- null --></A>
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<A HREF="#SEC1"><IMG WIDTH=11 HEIGHT=9 BORDER=0 HSPACE=5 ALT=" "
SRC="/icons/toc/darrow.gif">Diagnosis and Imaging<BR></A>
<A HREF="#SEC2"><IMG WIDTH=11 HEIGHT=9 BORDER=0 HSPACE=5 ALT=" "
SRC="/icons/toc/darrow.gif">Shrapnel Management/Removal<BR></A>
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<BR>
<I>
With the increased incidence of terrorism worldwide, it is important<SUP> </SUP>for surgeons to understand the role of shrapnel injury in mass<SUP> </SUP>casualty events. Several diagnostic modalities are available,<SUP> </SUP>including plain radiography, computed tomography, ultrasound,<SUP> </SUP>angiography, and computerized surgical navigation based on real-time<SUP> </SUP>acquisition of fluoroscopic data. Shrapnel management techniques<SUP> </SUP>are selected based on the following chronologic phases: acute,<SUP> </SUP>subacute, and late.<SUP> </SUP><P>
</I>
Shrapnel injuries were once confined to the battlefield. Today,<SUP> </SUP>these wounds are more frequently being seen in noncombatants<SUP> </SUP>because of the increase in terrorist acts worldwide. Explosive<SUP> </SUP>devices are the preferred weapon in terrorism because they are<SUP> </SUP>relatively cheap and can cause a large number of casualties.<SUP> </SUP>Musculoskeletal injuries are the most common modern warfare<SUP> </SUP>wounds, accounting for 60% to 70% of all wounds.<SUP><A HREF="#JA-S-00015-04-B1">1,2</A></SUP> Most penetrating<SUP> </SUP>injuries are inflicted by shrapnel, not bullets. The high speed<SUP> </SUP>of chemical decomposition of the explosive into gas (detonation)<SUP> </SUP>generates primary blast waves, which cause primary insult to<SUP> </SUP>gas-containing organs. Secondary blast injuries are inflicted<SUP> </SUP>by objects that have been energized by the explosion and thus<SUP> </SUP>have become projectiles. This shrapnel most often affects the<SUP> </SUP>musculoskeletal system; it is driven into both soft and osseous<SUP> </SUP>tissues, causing local damage or infection.<SUP><A HREF="#JA-S-00015-04-B3">3</A></SUP> The debate continues<SUP> </SUP>as to why, when, and how shrapnel should be removed.<SUP> </SUP><P>
Imaging techniques are used for patient diagnosis, shrapnel<SUP> </SUP>localization, and determining the timing and extent of treatment.<SUP> </SUP>Shrapnel management/removal is chronologically divided into<SUP> </SUP>acute, subacute, and late phases. In the acute phase, the victim<SUP> </SUP>is treated according to Advanced Trauma Life Support (ATLS)<SUP> </SUP>guidelines.<SUP><A HREF="#JA-S-00015-04-B4">4</A></SUP> Depending on the amount of energy of the blast,<SUP> </SUP>anatomic site, and related injuries, specific wound care and<SUP> </SUP>thorough débridement is performed with or without shrapnel<SUP> </SUP>removal. In general, shrapnel is left inert in the tissue and<SUP> </SUP>is removed at a later (subacute) stage only when absolutely<SUP> </SUP>necessary, such as in cases of systemic toxicity or local tissue<SUP> </SUP>complications (eg, abscess, foreign body granuloma)<SUP><A HREF="#JA-S-00015-04-B5">5,6</A></SUP> (<A HREF="#JAS0001504FIG1">Figure 1</A>).<SUP> </SUP><P>
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Figure 1 Metallic shrapnel in the tibia of a patient who was asymptomatic for 36 years.<B> A,</B> Anteroposterior plain radiograph of the left tibia demonstrating shrapnel in the diaphysis.<B> B,</B> Axial computed tomography scan demonstrating shrapnel in the cortex of the tibia. Note the wide reactive bone around the metal shard. <B>C,</B> Bone scan demonstrating high uptake around the shrapnel, indicating active bony process.<P>
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Diagnosis and Imaging
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In recent years, radiology has played an important role in the<SUP> </SUP>medical workup of victims of terrorist attack. Imaging technology,<SUP> </SUP>including plain radiography, computed tomography (CT), ultrasound,<SUP> </SUP>and angiography, is used to assess the site and extent of injury.<SUP> </SUP>These examinations also are important in determining the timing<SUP> </SUP>of surgery (immediate versus late).<SUP><A HREF="#JA-S-00015-04-B7">7</A></SUP><SUP> </SUP><P>
Plain radiographs, which are routinely obtained in patients<SUP> </SUP>with skeletal trauma, usually are sufficient to determine the<SUP> </SUP>presence and location of shrapnel as well as the diagnosis of<SUP> </SUP>bone fractures; generally, no additional studies are needed.<SUP> </SUP>With abdominal, chest, pelvic, head, or spinal involvement,<SUP> </SUP>additional studies often are needed to distinguish the location<SUP> </SUP>and proximity to vital organs.<SUP> </SUP><P>
CT is useful in identifying the precise anatomic location of<SUP> </SUP>most shrapnel that is metallic in nature. Because it is a static<SUP> </SUP>study, however, it does not contribute to understanding the<SUP> </SUP>dynamic relation of the shrapnel to other structures.<SUP> </SUP><P>
In contrast, ultrasound is useful not only in diagnosing shrapnel<SUP> </SUP>in soft tissues but also in demonstrating the dynamic relationship<SUP> </SUP>with other structures, such as proximity to tendons or movement<SUP> </SUP>within a joint. In addition, ultrasound can detect nonmetal<SUP> </SUP>shrapnel. Anecdotally, ultrasound has been reported as a useful<SUP> </SUP>tool in the rapid detection of shrapnel composition (eg, depleted<SUP> </SUP>uranium).<SUP><A HREF="#JA-S-00015-04-B8">8</A></SUP> Ultrasound equipment is portable and available for<SUP> </SUP>intraoperative localization.<SUP> </SUP><P>
Fluoroscopy is useful in diagnosis and localization, especially<SUP> </SUP>intraoperatively. The multiple projections of the image intensifier<SUP> </SUP>enable three-dimensional localization of the shrapnel, based<SUP> </SUP>on two-dimensional projections. In mass casualty events, there<SUP> </SUP>is an overwhelming exhaustion of imaging resources;<SUP><A HREF="#JA-S-00015-04-B9">9</A></SUP> the availability<SUP> </SUP>of fluoroscopy both reduces the need for other imaging resources<SUP> </SUP>and facilitates case handling.<SUP> </SUP><P>
The constant trade-off between tissue damage as a complication<SUP> </SUP>of surgery and the benefits of nonacute shrapnel removal led<SUP> </SUP>to the search for minimally invasive approaches for removal.<SUP> </SUP>As a result, other high-tech modalities have been added to the<SUP> </SUP>armamentarium of intraoperative imaging and detection, such<SUP> </SUP>as computerized surgical navigation based on real-time acquisition<SUP> </SUP>of fluoroscopic data. In this technique, several fluoroscopic<SUP> </SUP>images of the specific anatomic site are obtained. Accurate<SUP> </SUP>spatial location of the foreign object is seen on images displayed<SUP> </SUP>on the computer screen, with no further fluoroscopic radiation<SUP> </SUP>necessary. During surgery, an infrared camera tracks the position<SUP> </SUP>of a surgical probe on the image of the patient’s anatomy<SUP> </SUP>and continuously updates the probe’s three-dimensional<SUP> </SUP>position simultaneously on all displayed images until the location<SUP> </SUP>of the shrapnel is reached.<SUP><A HREF="#JA-S-00015-04-B10">10</A></SUP><SUP> </SUP><P>
The physician should be aware of the possibility of penetrating<SUP> </SUP>injury caused by foreign human tissues or blood carried by the<SUP> </SUP>shrapnel from suicide bombers or innocent bystanders. Mass casualty<SUP> </SUP>event treatment protocols should address the potential for infection<SUP> </SUP>from blood-borne pathogens in any patient who may have come<SUP> </SUP>in contact with tissues or body fluids.<SUP><A HREF="#JA-S-00015-04-B12">12</A></SUP> Because these are<SUP> </SUP>not bacterial infections, shrapnel removal to avoid contamination<SUP> </SUP>generally is not an issue. In these cases, immunologic treatment<SUP> </SUP>is necessary.<SUP> </SUP><P>
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Shrapnel Management/Removal
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Shrapnel management/removal is chronologically divided into<SUP> </SUP>acute, subacute, and late phases.<SUP> </SUP><P>
<STRONG>Acute Phase</STRONG><BR>
The acute phase involves shrapnel removal at the time of injury.<SUP> </SUP>The fundamental principles guiding shrapnel wound management<SUP> </SUP>are proper evaluation and excision of necrotic or contaminated<SUP> </SUP>tissue. Although war surgery literature stresses the need for<SUP> </SUP>complete wound débridement, this task is not an easy<SUP> </SUP>one; frequently, it is inadequately performed.<SUP><A HREF="#JA-S-00015-04-B13">13</A></SUP><SUP> </SUP><P>
High-velocity (>1,800 m/s) projectiles are thought to cause<SUP> </SUP>more tissue damage than low-velocity projectiles. It is presumed<SUP> </SUP>that the higher velocity results in much greater energy being<SUP> </SUP>absorbed by the victim, as illustrated by the physics equation<SUP> </SUP><I>E = <IMG SRC="/math/frac12.gif" ALT="1/2" BORDER="0">mv<SUP>2</SUP></I>. This is not exactly true, however. Many bullets do<SUP> </SUP>not efficiently impart all of their velocity into the victim.<SUP><A HREF="#JA-S-00015-04-B14">14-16</A></SUP><SUP> </SUP>In fact, high-velocity military bullets are less damaging to<SUP> </SUP>soft tissue, in particular, when exiting the body.<SUP> </SUP><P>
Bowyer et al<SUP><A HREF="#JA-S-00015-04-B17">17</A></SUP> indicated that most casualties who reach surgical<SUP> </SUP>facilities alive were struck by fragments with initial velocity<SUP> </SUP><600 m/s. The aerodynamic drag of these irregularly shaped<SUP> </SUP>projectiles results in deceleration outward from the point of<SUP> </SUP>detonation.<SUP><A HREF="#JA-S-00015-04-B18">18-20</A></SUP> Depending on the distance from the blast, fragments<SUP> </SUP>that strike the body can range from high to low velocity. In<SUP> </SUP>addition to their lack of streamlining, as with bullets fired<SUP> </SUP>through a rifle barrel, there are other ways in which low-velocity<SUP> </SUP>fragments from explosive ammunition behave differently from<SUP> </SUP>low-velocity bullets. Upon striking tissues, even at low velocities,<SUP> </SUP>these fragments may exhibit the tumbling or so-called shimmy<SUP> </SUP>effect, which can increase the amount of tissue damage. Additionally,<SUP> </SUP>these shrapnel usually carry environmental debris into the wound,<SUP> </SUP>frequently causing more severe tissue injury than do low-velocity<SUP> </SUP>bullets. For these reasons, mandatory wide débridement<SUP> </SUP>of high-velocity wounds is no longer recommended. This information<SUP> </SUP>has not yet entered the mainstream surgical literature, however.<SUP><A HREF="#JA-S-00015-04-B21">21,22</A></SUP><SUP> </SUP><P>
Shrapnel wounds should be treated on a case-by-case basis using<SUP> </SUP>this fundamental principle to guide management: evaluate and<SUP> </SUP>excise necrotic or contaminated tissues. The four C’s<SUP> </SUP>of muscle viability (color, consistency, capacity to bleed,<SUP> </SUP>contractility) are used to assess what needs to be excised.<SUP> </SUP>This is subjective, however, and greatly depends on surgeon<SUP> </SUP>experience.<SUP><A HREF="#JA-S-00015-04-B23">23</A></SUP> Serial débridement is often necessary in<SUP> </SUP>high-risk injuries (eg, excision of muscle that is merely questionable<SUP> </SUP>at first assessment but may become necrotic at a later stage).<SUP> </SUP>Shrapnel in the wound tract is usually removed during the acute<SUP> </SUP>stage; other shrapnel is either left for delayed removal or<SUP> </SUP>retained in the tissue for life.<SUP> </SUP><P>
It can be difficult to predict whether a shrapnel injury has<SUP> </SUP>a high potential for infection and thus requires débridement.<SUP> </SUP>Experienced clinical judgment is necessary to make that determination.<SUP> </SUP>Factors that help the surgeon determine whether the wound is<SUP> </SUP>high- or low-risk include time to treatment, path of the projectile,<SUP> </SUP>bone involvement, and the number of projectiles.<SUP><A HREF="#JA-S-00015-04-B23">23</A></SUP><SUP> </SUP><P>
In the acute phase, damage control principles are applied. Only<SUP> </SUP>lifesaving procedures are performed to hemodynamically stabilize<SUP> </SUP>the patient.<SUP><A HREF="#JA-S-00015-04-B4">4</A></SUP> Once the patient is stabilized, shrapnel should<SUP> </SUP>be left in the tissue until the emergency condition has subsided.<SUP> </SUP><P>
<STRONG>Subacute Phase</STRONG><BR>
In the subacute phase, retained shrapnel removal is indicated<SUP> </SUP>in several instances: when infection is suspected, in the presence<SUP> </SUP>of periarticular involvement, in weight-bearing areas, with<SUP> </SUP>superficially located shrapnel, or in proximity to neurovascular<SUP> </SUP>structures.<SUP><A HREF="#JA-S-00015-04-B24">24</A></SUP> In addition, significant large fragments that<SUP> </SUP>affect normal functioning should be removed.<SUP> </SUP><P>
<FONT SIZE=-1><STRONG>Periarticular Involvement</STRONG></FONT><BR>
High-energy projectiles are likely to carry foreign material<SUP> </SUP>into the joint. The surgeon should not hesitate to surgically<SUP> </SUP>explore the wound. Apart from posing an infection hazard, any<SUP> </SUP>foreign material in the joint may cause mechanical abrasion<SUP> </SUP>and joint destruction, and fragments passing through the joint<SUP> </SUP>may cause ligamentous or meniscal injury.<SUP><A HREF="#JA-S-00015-04-B23">23,25,26</A></SUP> Fragments<SUP> </SUP>in the periarticular area (eg, the bursae) also should be removed.<SUP> </SUP>Another indication for removal is in the presence of superficial<SUP> </SUP>shrapnel under the skin and in patients whose weight-bearing<SUP> </SUP>surfaces become painful to the touch and to external pressure.<SUP> </SUP><P>
<FONT SIZE=-1><STRONG>Nerve Involvement</STRONG></FONT><BR>
Nerve palsy is a common finding with shrapnel injury. Because<SUP> </SUP>it is usually temporary, neurapraxia in itself is not an indication<SUP> </SUP>for exploration. When shrapnel is located near nerve structures<SUP> </SUP>and there is irritation of the nerve with progressive neurologic<SUP> </SUP>signs or symptoms, however, nerve exploration with shrapnel<SUP> </SUP>removal is indicated. Omer<SUP><A HREF="#JA-S-00015-04-B27">27</A></SUP> reported a recovery rate of up<SUP> </SUP>to 70%, usually within 6 to 9 months of injury, for gunshot<SUP> </SUP>wounds with neurologic symptoms. A transected nerve should be<SUP> </SUP>repaired after the inflammatory phase has subsided and when<SUP> </SUP>there are no signs of infection. Shrapnel removal is indicated<SUP> </SUP>whenever exposure of the nerve is performed. Recovery after<SUP> </SUP>nerve repair is reported to be 25%.<SUP><A HREF="#JA-S-00015-04-B27">27</A></SUP><SUP> </SUP><P>
<STRONG>Late Phase</STRONG><BR>
Retained fragments are usually benign, and the surgeon should<SUP> </SUP>not attempt to remove them.<SUP><A HREF="#JA-S-00015-04-B26">26</A></SUP> After recovery from the preliminary<SUP> </SUP>injury, most patients are asymptomatic. The shrapnel gradually<SUP> </SUP>becomes encased in fibrous tissue and is considered inert.<SUP><A HREF="#JA-S-00015-04-B25">25,28</A></SUP><SUP> </SUP>Rarely, however, shrapnel causes harm in the long term, either<SUP> </SUP>in the form of systemic damage as a result of shrapnel degradation<SUP> </SUP>or because of a local foreign- body reaction. For example, large<SUP> </SUP>lead shrapnel retained in soft tissue can cause plumbism.<SUP><A HREF="#JA-S-00015-04-B5">5</A></SUP> Chronic<SUP> </SUP>plumbism (lead toxicity) should be considered in patients with<SUP> </SUP>retained lead shrapnel, and a history should be taken to assess<SUP> </SUP>the presence of symptoms attributable to plumbism. These patients<SUP> </SUP>may require long-term follow-up to assess the development of<SUP> </SUP>elevated blood lead levels and lead toxicity.<SUP><A HREF="#JA-S-00015-04-B5">5</A></SUP> The first widespread<SUP> </SUP>use of depleted uranium was seen in the early 1990s during the<SUP> </SUP>Gulf War. The kidney uranium concentration in some individuals<SUP> </SUP>reached its peak 6 years after the war.<SUP><A HREF="#JA-S-00015-04-B29">29</A></SUP> Depleted uranium degradation<SUP> </SUP>causes multi-organ toxicity.<SUP><A HREF="#JA-S-00015-04-B29">29</A></SUP><SUP> </SUP><P>
Malignant processes have been reported in conjunction with the<SUP> </SUP>prolonged presence of shrapnel.<SUP><A HREF="#JA-S-00015-04-B15">15,30</A></SUP> Cases of delayed aneurysm<SUP> </SUP>and abscess at the site of a retained foreign body<SUP><A HREF="#JA-S-00015-04-B6">6,31</A></SUP> as well<SUP> </SUP>as foreign-body granulomas and reactions have been described.<SUP> </SUP>Nevertheless, considering the morbidity involved in surgical<SUP> </SUP>removal, these rare incidents do not justify the surgical removal<SUP> </SUP>of shrapnel in all cases.<SUP><A HREF="#JA-S-00015-04-B26">26</A></SUP><SUP> </SUP><P>
A relatively new reason for shrapnel removal is the clinical<SUP> </SUP>indication for a magnetic resonance imaging (MRI) study. This<SUP> </SUP>examination cannot be safely performed on patients with retained<SUP> </SUP>shrapnel because patients who undergo MRI examination may suffer<SUP> </SUP>from magnetic effects on the shrapnel (eg, pain, bruises, injury<SUP> </SUP>to nerves or blood vessels in the vicinity of the shrapnel).<SUP> </SUP>Thus, shrapnel removal is indicated before performing an MRI<SUP> </SUP>study.<SUP><A HREF="#JA-S-00015-04-B28">28</A></SUP><SUP> </SUP><P>
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The increase in terrorism worldwide makes it crucial for surgeons<SUP> </SUP>to understand the major role of shrapnel injuries in mass casualty<SUP> </SUP>events. Proper diagnosis, understanding the indications for<SUP> </SUP>and the timing of shrapnel removal, and careful follow-up may<SUP> </SUP>improve event management and patient outcome, and may reduce<SUP> </SUP>the number of unnecessary procedures.<SUP> </SUP><P>
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<SUP> </SUP><P>
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Figure 2 <B>A,</B> Shrapnel in the hip joint. <B>B,</B> The surgeon removes the shrapnel through a small incision, using Iso-C 3D navigation. <B>C,</B> Tracked grasper holding the shrapnel.<P>
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References
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<A HREF="#ABS"><IMG WIDTH=11 HEIGHT=9 BORDER=0 HSPACE=5 ALT=" "
SRC="/icons/toc/uarrow.gif">Abstract<BR></A>
<A HREF="#SEC1"><IMG WIDTH=11 HEIGHT=9 BORDER=0 HSPACE=5 ALT=" "
SRC="/icons/toc/uarrow.gif">Diagnosis and Imaging<BR></A>
<A HREF="#SEC2"><IMG WIDTH=11 HEIGHT=9 BORDER=0 HSPACE=5 ALT=" "
SRC="/icons/toc/uarrow.gif">Shrapnel Management/Removal<BR></A>
<A HREF="#SEC3"><IMG WIDTH=11 HEIGHT=9 BORDER=0 HSPACE=5 ALT=" "
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SRC="/icons/toc/dot.gif"><FONT COLOR=464c53>References</FONT><BR>
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<OL COMPACT>
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