1. Gunshot injuries to joints can cause high morbidity due to complications like fractures, infection, lead poisoning and arthropathy. 2. Lead from retained bullet fragments or shrapnel in the joint can induce lead synovitis and accelerate the development of degenerative arthritis within weeks. 3. Evaluation of intra-articular gunshot injuries involves clinical exam, radiographs, labs to check for lead toxicity, and other imaging like CT. Surgical removal of lead fragments is usually recommended to prevent long term complications.

1. Management of intra articular
Firearm Injuries
(The poison shot)
Mohamed Abulsoud (M.D)
Lecturer of orthopedic surgery
Faculty of medicine – Al-Azhar university
Cairo- Egypt

2. ILO
• Introduction
• Ballistics
• Complications
• Evaluation
• Treatment

3. • In the United States, someone suffers a
gunshot wound every 4 minutes and 44
seconds and a person dies as a result each 16
minutes .
• Gunshot injuries of the joint are associated
with a high morbidity compared with other
gunshot wounds

4. Firearm broadly classified into three types:
1. low velocity (<350 m/s)
2. medium velocity (350 – 600 m/s)
3. high velocity (>600 m/s)

5. Ballistics

6. • Close to Neurovascular bundle
• Contamination
• Sometimes overlooked
• Fractures
• Arthropathy
• Systemic manifestations
(plumbism)

7. • Lead is soluble in synovial fluid and induces
lead synovitis and degenerative arthritis
Lewin L, & Leonard MH Clin Orthop 1969;64:255-261
• Linden M, Manton W, Stewart R, et alAnn Surg. 1982;195(3):305–313
• Animal studies have demonstrated significant
articular degeneration with implantation of
lead into rabbit knees compared with controls
• Bolanos AA, Vigorita VJ, Meyerson RI, et al J Trauma. 1995;38(4):668–671.
• Harding NR, Lipton JF, Vigorita VJ, et al J Trauma. 1999;47(5):951–955

8. Gameiro VS, et al. BMJ Case Rep 2013

9. • Early changes (1 to 2 weeks) :
synovial hyperplasia, mild
inflammation, and articular
surface slit formation.
• Late changes(3 to 6 weeks) :
Giant cells and foreign particles in
the synovium, focal chondrocyte
proliferation and disorganization.

10. • Rare but serious complication.
• Lead intoxication (plumbism) can manifest
from 2 days to 40 years after a gunshot injury.
• Rapidly accelerates in the presence of
metabolic disorders, alcoholism, or acute
infection.

11. • Approximately 90% to 95% of lead is stored in
bone, taking the place of calcium in the
calcium hydroxyapatite.
• The half-life of lead in bone is 20 to 30 years.
• Blood half-life is 30 days.

12. • The normal blood lead level for adults is 0 to
19 μg/dL.
• The highest blood lead level deemed
acceptable is 40 μg/dL. (OSHA 2001)

14. • Treatment
1 Removal
2 Chelating agents
Dimercaptosuccinic acid (DMSA)
D-penicillamine
CaNa2 EDTA
Dimercaprol

15. • Clinical
ABCDE
Wound inlet & exit
Neurovascular
ROM
Signs of systemic lead toxicity

16. • Investigations
• Lab (CBC,ESR,Serum
lead, Creatinine,……)
• X ray
• CT
• (occult fr, localization)
• CT Angiography
• MRI (Safety???)
(not recommended )

17. • Surgical removal
• Lavage.
• Arthrotomy
Associated Intra articular fractures
Infection
Recent with open tract
CS

18. Courtsey Prof Ahmed Akar
Dr Samir Nematalla

19. S. Maqungo, et al, Injury (2016)

20. • Advantages
1 Less invasive
2 Better visualization
3 Address intra articular injuries (OCD,Meniscus..)

21. • In a review of 33 gunshot wounds to the knee
without radiographic evidence of injury,
Arthroscopy showed abnormalities in 24 cases
(72%)
• 5 chondral injuries, 14 meniscal injuries, and
5 cases with intra articular debris not seen on
radiographs
• Tornetta P and,Hui RC. J Orthop Trauma. 1997;11(6):422–424.

22. • Disadvantage
1. Equipments
2. Technicaly demanding (Hip,Elbow)
3. Expertise
4. Complications (CS)

23. • Tips for arthroscopic retrieval
Fluoroscopy
Low pump pressure
Remove then explore
Use a nearby portal
Adequate Portal incision
Debridement and lavage
Suction drain

24. K. LACY ET AL.Arthroscopy Techniques, 2016

25. Gupta and Aggarwal et al . IJO, 2009

26. • Intra Articular gunshot fragment (bullet,bellet
or shrapnel )should be retrieved.
• Systemic lead poisoning is rare but serious
complication
• Lead Synovitis and arthropathy occurs as early
as few weeks
• Removal could be by arthrotomy or
arthroscopy