Current Radiology Reports

, 6:45 | Cite as

Ballistic Injury Imaging: The Basics

  • Noah DitkofskyEmail author
  • Khaled Y. Elbanna
  • Jason Robins
  • Ismail Tawakol Ali
  • Michael O’Keeffe
  • Ferco H. Berger
Emergency Radiology (J Yu, Section Editor)
Part of the following topical collections:
  1. Emergency Radiology



As of 2007, there were estimated to be at least 750 million firearms in worldwide circulation, of which 650 million of them were owned by civilians (Weiss et al. in Severe lead toxicity attributed to bullet fragments retained in soft tissue. BMJ Case Reports, 2017). Of these, approximately 270 million are in the United States, equating to 84 guns per 100 Americans [based on 2016 population statistics (assuming the number of firearms remained stable over the intervening 9 years)] and resulting in 84 997 nonfatal injuries and 36 252 fatalities in the United States in 2015. With statistics like these, it stands to reason that victims of gunshot wounds (GSW) will be imaged by most radiologists at least once in their careers. This article seeks to increase radiologists’ knowledge of the pathophysiology of GSW and will review the mechanism of ballistic injury and relate these to commonly encountered imaging findings.

Important Points

Ballistic injuries are a combination of the direct injury caused by the bullet along its path through the tissues and the shockwave created around that path as the bullet expends its energy. CT is the gold standard in ballistic injury assessment. MRI is not contraindicated in patients with retained ballistic fragments, but should be used with caution. The number of entry/exit wound and the number of retained ballistic fragments should be an even number, or there is a missing surface wound or a missing bullet. Retained lead in joints can result in plumbism and arthropathy.


As most radiologists will encounter a ballistic injury in the course of their careers, an understanding of this unique mechanism of injury and its complications will aid in both imaging interpretation and patient care.


Ballistic injury imaging Emergency radiology GSW victims Pathophysiology of GSW 



The authors would like to thank Dr. Monique Christakis and Dr. Joel Rubenstein as well as the executive of the Toronto Revolver Club for their support and assistance.

Compliance with Ethical Guidelines

Conflict of interest

Noah Ditkofsky, Khaled Y. Elbanna, Jason Robins, Ismail Tawakol Ali, Michael O’Keeffe, and Ferco H. Berger each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Recently published papers of particular interest have been highlighted as: • Of importance

  1. 1.
    Canadian firearms safety course. 5th edition. ed. 1 online resource.Google Scholar
  2. 2.
    • Dedini RD, et al. MRI issues for ballistic objects: information obtained at 1.5-, 3- and 7-Tesla. Spine J. 2013;13(7):815–22. This article discusses the MRI safety of ballisic debris. It is a good reference for methodology as well as to provide additional information on this topic. CrossRefGoogle Scholar
  3. 3.
    Lozano JD, et al. Penetrating wounds to the Torso: evaluation with triple-contrast multidetector CT. RadioGraphics. 2013;33(2):341–59.CrossRefGoogle Scholar
  4. 4.
    Dreizin D, Munera F. Multidetector CT for penetrating Torso trauma: state of the art. Radiology. 2015;277(2):338–55.CrossRefGoogle Scholar
  5. 5.
    Gunn ML, et al. Current concepts in imaging evaluation of penetrating transmediastinal injury. RadioGraphics. 2014;34(7):1824–41.CrossRefGoogle Scholar
  6. 6.
    Reginelli A, et al. Imaging assessment of gunshot wounds. Semin Ultrasound CT MR. 2015;36(1):57–67.CrossRefGoogle Scholar
  7. 7.
    Daghfous A, et al. Contribution of imaging in the initial management of ballistic trauma. Diagn Interv Imaging. 2015;96(1):45–55.CrossRefGoogle Scholar
  8. 8.
    • Dreizin D, et al. Penetrating diaphragmatic injury: accuracy of 64-section multidetector CT with trajectography. Radiology. 2013;268(3):729–37. Diaphragmatic injuries are a common indication for surgical intervention. This article discusses the use of trajectography in assessing for diaphragmatic injuries. CrossRefGoogle Scholar
  9. 9.
    Dreizin D, et al. Penetrating colorectal injuries: diagnostic performance of multidetector CT with trajectography. Radiology. 2016;281(3):749–62.CrossRefGoogle Scholar
  10. 10.
    Ramirez RM, et al. Single-contrast computed tomography for the triage of patients with penetrating torso trauma. J Trauma. 2009;67(3):583–8.CrossRefGoogle Scholar
  11. 11.
    Holmes JF, et al. Performance of helical computed tomography without oral contrast for the detection of gastrointestinal injuries. Ann Emerg Med. 2004;43(1):120–8.CrossRefGoogle Scholar
  12. 12.
    Chiu WC, et al. Determining the need for laparotomy in penetrating torso trauma: a prospective study using triple-contrast enhanced abdominopelvic computed tomography. J Trauma. 2001;51(5):860–8 discussion 868-9.CrossRefGoogle Scholar
  13. 13.
    Shanmuganathan K, et al. Triple-contrast helical CT in penetrating torso trauma: a prospective study to determine peritoneal violation and the need for laparotomy. AJR Am J Roentgenol. 2001;177(6):1247–56.CrossRefGoogle Scholar
  14. 14.
    Munera F, et al. Gunshot wounds of abdomen: evaluation of stable patients with triple-contrast helical CT. Radiology. 2004;231(2):399–405.CrossRefGoogle Scholar
  15. 15.
    • Jawad H, et al. Single-contrast CT for detecting bowel injuries in penetrating abdominopelvic trauma. AJR Am J Roentgenol. 2018:1–5. This article discusses the omission of rectal contrast in penetrating trauma. Google Scholar
  16. 16.
    Mongan J, et al. Extravasated contrast material in penetrating abdominopelvic trauma: dual-contrast dual-energy CT for improved diagnosis–preliminary results in an animal model. Radiology. 2013;268(3):738–42.CrossRefGoogle Scholar
  17. 17.
    Hollerman JJ, et al. Gunshot wounds: 1. Bullets, ballistics, and mechanisms of injury. AJR Am J Roentgenol. 1990;155(4):685–90.CrossRefGoogle Scholar
  18. 18.
    Wilson AJ. Gunshot injuries: what does a radiologist need to know? Radiographics. 1999;19(5):1358–68.CrossRefGoogle Scholar
  19. 19.
    Amadasi A, et al. Characteristics and frequency of chipping effects in near-contact gunshot wounds. J Forensic Sci. 2017;62(3):786–90.CrossRefGoogle Scholar
  20. 20.
    DiMaio VJM. Gunshot wounds: practical aspects of firearms, ballistics, and forensic techniques. 2nd ed. Boca Raton: CRC Press; 1998.CrossRefGoogle Scholar
  21. 21.
    Mann M, et al. Shot pellets: an overview. Assoc Firearm Tool Mark Exam J, 1994. 26(3).Google Scholar
  22. 22.
    de Oliveira RM, Drumond DAF. Considerations about ballistic embolism: experience at the João XXIII Hospital. Rev Med Minas Gerais. 2014;24(4):527–34.Google Scholar
  23. 23.
    Miller KR, et al. The evolving management of venous bullet emboli: a case series and literature review. Injury. 2011;42(5):441–6.CrossRefGoogle Scholar
  24. 24.
    Greaves N. Gunshot bullet embolus with pellet migration from the left brachiocephalic vein to the right ventricle: a case report. Scand J Trauma Resusc Emerg Med. 2010;18:36.CrossRefGoogle Scholar
  25. 25.
    Aoun T, Amine F, Ziad K. Femoral artery embolization of a thoracic stray bullet. J Vasc Surg Cases Innov Tech. 2017;3(3):123–5.CrossRefGoogle Scholar
  26. 26.
    Wilkins T, Rosenkranz ER, Nguyen D. Venous bullet embolus to the left pulmonary artery. J Card Surg. 2016;31(8):523–5.CrossRefGoogle Scholar
  27. 27.
    Landim RM, Evelyn Soares Filho AW, Cardoso DL. Femoral artery embolism of bullet after thoracic gunshot wound. J Vasc Surg Cases Innov Tech. 2017;3(3):186–7.CrossRefGoogle Scholar
  28. 28.
    Huang J, et al. Popliteal artery embolism of bullet after abdominal gunshot wound. Radiol Case Rep. 2016;11(4):282–6.CrossRefGoogle Scholar
  29. 29.
    Nolan T, et al. Bullet embolization: multidisciplinary approach by interventional radiology and surgery. Semin Interv Radiol. 2012;29(3):192–6.CrossRefGoogle Scholar
  30. 30.
    Sclafani SJ, Vuletin JC, Twersky J. Lead arthropathy: arthritis caused by retained intra-articular bullets. Radiology. 1985;156(2):299–302.CrossRefGoogle Scholar
  31. 31.
    Fernandes JL, et al. Lead arthropathy: radiographic, CT and MRI findings. Skelet Radiol. 2007;36(7):647–57.CrossRefGoogle Scholar
  32. 32.
    McAninch SA, et al. Bullet fragment-induced lead arthropathy with subsequent fracture and elevated blood lead levels. Proc (Bayl Univ Med Cent). 2017;30(1):88–91.CrossRefGoogle Scholar
  33. 33.
    Ramji Z, Laflamme M. Ankle lead arthropathy and systemic lead toxicity secondary to a gunshot wound after 49 years: a case report. J Foot Ankle Surg. 2017;56(3):648–52.CrossRefGoogle Scholar
  34. 34.
    Weiss D, et al. Severe lead toxicity attributed to bullet fragments retained in soft tissue. BMJ Case Reports; 2017. 2017.Google Scholar
  35. 35.
    Weiss D, et al. Elevated blood lead levels associated with retained bullet fragments—United States, 2003-2012. MMWR Morb Mortal Wkly Rep. 2017;66(5):130–3.CrossRefGoogle Scholar
  36. 36.
    Abraham A, et al. Pain from a bullet lingers on: an uncommon case of lead toxicity. Case Rep Gastroenterol. 2012;6(2):243–8.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Noah Ditkofsky
    • 1
    Email author
  • Khaled Y. Elbanna
    • 1
  • Jason Robins
    • 1
  • Ismail Tawakol Ali
    • 1
  • Michael O’Keeffe
    • 1
  • Ferco H. Berger
    • 1
  1. 1.Medical Imaging – Emergency & Trauma Radiology DivisionSunnybrook Health Sciences CenterTorontoCanada

Personalised recommendations