Mechanisms of Penetrating Trauma To The Neck: Ranjan Gupta, MD, Sushruta Nagarkatti, MD

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ARTICLE IN PRESS [mUS6b;October 27, 2020;19:4]

Operative Techniques in Otolaryngology xxx (xxxx) xxx
Mechanisms of Penetrating Trauma to the Neck

Ranjan Gupta, MD, Sushruta Nagarkatti, MD
From the Department of Surgery, Bronxcare Health System, Bronx, New York
Available online xxx
KEYWORDS Purpose: There are enough firearms in the United States that every man, woman and child can
penetrating neck have one and still 67 million would be left over. Penetrating trauma from firearms has increased
trauma; recently with easier availability of military grade weapons to civilians and an increased incidence
firearm injury; of terrorism. Understanding of wound ballistics has a definite role in the betterment of neck trauma
wound ballistics management. This article discusses the mechanisms of penetrating neck trauma with special emphasis
on penetrating projectile trauma and a brief introduction of types of firearms and their evolution.
Important points: All firearms work on the same basic mechanism which has evolved over centuries
since the Chinese discovered gunpowder. The cartridge is the basic unit of a firearm containing
the casing, propellant, primer and actual bullet or projectile. High velocity rifles and low velocity
handguns revolve around modifications in the structure of cartridge used and the properties of the
firearm. Once fired, the projectile achieves muzzle velocity which is subject to slowing down from
gravity and atmospheric friction. As the projectile enters the target tissue, the amount of damage
sustained depends on the amount of energy transferred and the study of those factors is called
terminal ballistics.
Summary: Penetrating neck trauma carries significant morbidity and mortality even with advancement
of medical science. Understanding the mechanisms of ballistic trauma plays a crucial role in diagnosis
and management of these wounds and it is important for surgeons to understand the mechanisms by
which tissue damage is incurred.
© 2020 Elsevier Inc. All rights reserved.
Introduction tremendous proportion of gun ownership relates directly

to the number of mass shootings in the U.S. According
“There are more than 393 million civilian-owned to a study done over a 30 year period between 1983 and
firearms in the United States, or enough for every man, 2013, the U.S. had 78 mass shootings while the next 24
woman and child to own one and still have 67 million guns industrialized countries combined had 41 mass shootings.2
left over”.1 In 2017, out of 857 million firearms owned by These mass shootings are a result of civilians having ac-
civilians worldwide, 46% were owned by Americans.1 This cess to more and more military grade weapons. Moreover,
the increasing incidence of terrorist attacks adds to civilian
trauma at the hands of military grade weapons.3 , 4 Trauma
Address reprint requests and correspondence: Ranjan Gupta, MD,
Bronxcare Health System, 1650 Selwyn Avenue, Apt # 4A, Bronx, NY
surgeons and emergency room physicians taking care of
10457. these patients can adequately manage the patients only if
Sushruta Nagarkatti, MD, Bronxcare Health System, 1650 Selwyn Av- they understand the mechanisms by which these weapons
enue, Apt # 4A, Bronx, NY 10457. cause damage, and hence the significance of wound bal-
E-mail addresses: ranjandoc@gmail.com, sushruta@gmail.com
http://doi.org/10.1016/j.otot.2020.10.010
1043-1810/© 2020 Elsevier Inc. All rights reserved.
Please cite this article as: Ranjan Gupta and Sushruta Nagarkatti, Mechanisms of Penetrating Trauma to the Neck, Operative Techniques in Otolaryn-
gology - Head and Neck Surgery, https:// doi.org/ 10.1016/ j.otot.2020.10.010
Downloaded for Ranjan Gupta (gupta745@umn.edu) at University of Minnesota from ClinicalKey.com by Elsevier on November 24, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
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2 Operative Techniques in Otolaryngology, Vol 000, 2020
listics cannot be understated. Inappropriate management Stock

can result from erroneous beliefs and myths about wound The handle of the firearm, is usually made of wood or
ballistics and it can, in turn, add to morbidity of victims other synthetic material.6
already suffering from trauma.5 Wound ballistics are not
dependent on which body part is involved in trauma (eg,
extremity, torso, or neck) but rather they depend on the Types of firearms
composition of the tissues (muscle, bone, soft tissue etc.)
or the characteristics of the projectile (kinetic energy, com- Muzzleloaders
position etc.). Hence, the wound cavities created by differ- These firearms need to be loaded from the front open-
ent projectiles may be similar in different body parts with ing of the barrel. They need to be reloaded after each
the same composition but projectile injury becomes even shot, which is slow. A specific amount of black powder is
more significant when the neck is involved. As the neck is poured through muzzle followed by a patch and a projec-
a complex network of neurovascular and muscular struc- tile (ball, bullet, or shot). The rear of the barrel has a hole
tures covered by fascial planes and skin, the proximity of which allows ignition of powder by various mechanisms
vital organs makes the understanding of wound ballistics depending on the type of firearm used.6 Muzzleloaders are
even more relevant for physicians treating neck trauma. used in sporting activity (muzzleloading), target shooting,
Penetrating neck trauma can occur due to stab injuries hunting, historical re-enactment, and historical research.
from knives and other sharp objects as well as projectiles
launched from firearms. This type of trauma can cause Breechloaders
airway injury, pharyngo-esophageal injury, vascular injury Are firearms that can be loaded from the back. Early at-
or neurological injury. Stab injuries usually have a more tempts failed due to leakage of burning charge from the
predictable path and the management of these injuries is breech parts. The invention of cartridges made breechload-
based on zones of the neck which is discussed in detail ing practically possible. Pulling the trigger causes the fir-
in other articles in this journal. Projectile injuries, on the ing pin to strike the primer, a flash from primer ignites
other hand, are capable of damaging more tissue than is the propellant the burning of which expands the cartridge,
grossly visible to the eye. Hence, it is equally important which in turn launches the projectile and seals the breech
for physicians to understand the basics of wound ballistics to prevent leakage.6
to appropriately anticipate the extent of injury while treat-
ing such patients. For example, a gunshot wound through
the neck may not have penetrated the airway or esopha- Firearms evolution
gus but these structures could be damaged by temporary
cavitation which if not anticipated in advance could delay English alchemist Roger Bacon (1219-1292) is credited
the diagnosis and treatment of such injuries which could with inventing gunpowder. Alternatively, it is also believed
be detrimental to the patient. This paper discusses basic to have been used by the Chinese in fireworks and rockets
structure and types of firearms with some glimpse to the at the same time.7 It took centuries for firearms to evolve
history and evolution of firearms, with special emphasis on from gunpowder to modern ammunition.
ballistics and how it affects management of patients.
Cannon
Firearms One of the earliest weapons which used a burning black
powder to produce a rapidly expanding gas that forced
Typically, firearms consist of 3 major parts: the barrel, projectiles out of the open end of the barrel.6
action and stock (Figure 1).
Matchlocks
Barrel Discovered in 15th century, matchlocks were the first me-
The barrel is the tube (mostly metallic) through which the chanical firing devices which needed both hands to fire the
bullet travels when a firearm is fired. The opening from firearm which used a wick for ignition. This was problem-
which the bullet emerges is called the muzzle. Barrels usu- atic in cases of rain or wind.6
ally have a data stamp from the manufacturer to identify
the right cartridge to use. Rifles and shotguns have long
barrels, and handguns have short ones. Wheel-locks and flintlocks
Invented in 16th and 17th century respectively, these are
similar to matchlocks with different mechanisms for ignit-
Action ing the firearm. While the wheel-lock works like a cigarette
The action is the part of firearm which holds the cartridge lighter using a friction wheel to create a spark; the flint
in its chamber. The role of the action is to fire ammunition lock produces a spark by striking a flint against steel.
using a trigger as well as ejecting fired casings or unfired These mechanisms were complex and expensive; and sub-
cartridges. ject to wear and tear of the springs and flints.6
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Ranjan Gupta and Sushruta Nagarkatti 3
Figure 1 Parts of a basic firearm.
Percussion caps
Developed in the early 19th century, these were single
use ignition devices which use a small metal case or cap Bullet
containing explosive material which would explode when
struck. This brought weaponry one step closer to repeating-
use firearms and was resistant to rainy weather conditions.6
Metallic cartridge case

Cartridges
A cartridge or a round (popularly referred to as a bul-
Powder
let) is a pre-assembled firearm ammunition consisting of
a projectile (actual bullet or shot), a propellant substance
(black powder or smokeless powder) and an ignition device
(primer); packaged within a case (metallic, paper or plas-
tic). The cartridge is manufactured to precisely fit within Primer
the barrel chamber of a breechloading gun. Single use
firearms need the cartridge to be loaded each time while Figure 2 Cross section of a cartridge showing its parts.
repeated-use firearms contain a fixed or removable maga-
zine that contains multiple cartridges. Cartridges are easily (Figure 4). Shotgun pellets are round bearings completely
loaded into the breech, are mostly weatherproof and more made from lead or steel. Full metal jacket bullets do not
reliable. Shells are cartridges used for shotguns and contain fragment or mold inside the target and are designed to
multiple projectiles.6 pass through targets, resulting in less energy deposition
and hence less damage. SJ bullets deform because of un-
Types of bullets covered lead inside the target and are designed to stay
inside the target, hence maximizing energy deposition and
The term “bullet,”, often confused and used inter- damage to the target tissue whereas NJ bullets extensively
changeably with the cartridge, refers to just the pro- deform and fragment in the target tissue, resulting in com-
jectile part of handgun or rifle cartridge (Figure 2). plete energy deposition. Shotgun pellets spread and lose
“Caliber” is the term that usually identifies or charac- velocity (and hence energy) as they move farther from the
terizes a bullet. Caliber refers to bullet diameter, ex- muzzle and hence the damage greatly depends on distance
pressed either in millimeters (mm) or decimal frac- of the target from the muzzle.10
tion of an inch.8 , 9 Caliber is written on the head-
stamp of a cartridge along with the manufacturer’s name Penetrating neck trauma
(Figure 3). Full metal jacket (FMJ) bullets are made
of lead core completely covered by a metal sheath Penetrating neck injuries include stab injuries from
(jacket) which is made of copper or steel. Semi-jacketed knives, razor blades, glass etc., or projectile injuries from
(SJ) bullets are partially covered by a metal jacket and handguns, rifles or shotguns. Stab injuries are typically low
non-jacketed (NJ) bullets are made of lead completely velocity with a predictable path. Management is aimed at
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Figure 3 Examples of modern ammunition and cartridge head stamps.
treating the wounds and injured vital structures in the neck. involves pulling the trigger which activates the primer; the
The detailed management will be discussed in other arti- primer in turn ignites the propellant contained in the cas-
cles contained in this journal. In general, gunshot wound to ing. Propellant produces rapidly expanding hot gases when
the neck may appear small or may be completely destruc- it burns, which generates high pressure hence forcing the
tive. This depends on the range, velocity and caliber of the projectile (bullet) out of the casing into the barrel. The
projectile. Small caliber bullets may have a nearly negli- expanding gases further impart high kinetic energy to the
gible entrance wound but the damage caused by cavitation bullet increasing its velocity as it travels through the barrel,
may be extensive. Handgun injuries are usually considered until it exits the muzzle with its maximum velocity known
low velocity trauma whereas injuries from rifles are con- as muzzle velocity. The muzzle velocity would hence be
sidered high velocity trauma. determined by the amount of the propellant in the cartridge
With advanced radiologic and endoscopic techniques, which directly correlates to the weight of the cartridge (or
and selective neck exploration practiced by most surgeons; round) and the length of the barrel the bullet is travelling
the mortality from both low velocity and high velocity pen- down.16
etrating neck trauma has decreased to 3-6% from 7% with The effects of wind, velocity, drag, and gravity on the
mandatory neck exploration during World War II, and 16% projectile while in flight from barrel to target is termed
with nonsurgical management during World War I.11-13 external ballistics.14 , 15 As the projectile (bullet) leaves the
barrel through the muzzle, it starts slowing down due to
Ballistics friction from the medium (atmospheric air, water or tissue)
as well as force of gravity trying to pull it down; and hence
Ballistics is the study of flight of objects through the loses kinetic energy as it travels farther from the muzzle.
air. For different reasons, ballistics is studied by surgeons, So, the farther the target from the muzzle, the less energy
military, law enforcement personnel, and weapons man- a bullet will deposit in the target.16 In summary, the extent
ufacturers. Since civilians are increasingly becoming the of tissue injury caused by a bullet relies upon velocity of
targets of violence, often from ballistic weapons, under- the bullet, bullet structure itself (Jacketed, SJ, or NJ which
standing the ballistics of a projectile and its effect on hu- determines deformation of the bullet inside target tissue)
man tissues would certainly help surgeons in treating the and composition of the target tissue.17 , 18 These variables
wounds inflicted by these weapons.14 will define the energy deposited by a bullet in the target
Ballistics can be divided into 3 phases. Internal bal- tissue, hence the damage caused, which is consistent with
listics refers to the effects of design and composition of the Law of Conservation of Energy which states that “En-
both cartridge and the barrel.14 , 15 Shotgun barrels have a ergy can neither be created nor destroyed; energy can only
smooth internal contour and fire multiple pellets. Hand- be transferred or changed from one form to another.” In
guns and rifles fire a solitary projectile and have a barrel other words, tissue damage depends on the kinetic energy
with a spiral internal contour called “rifling” which is made of the bullet which is dependent on its mass and velocity
of ‘‘lands’’ which are outcropping and ‘‘grooves’’ which (KE = ½ M [V1 -V2 ]2 [where KE is Kinetic Energy trans-
are smooth.10 Rifling makes the bullet spin in the barrel ferred from the bullet to target tissue, M is mass of the bul-
which helps maintain the path to its objective after leaving let, V1 is the velocity of the bullet entering the target and
the muzzle and avoids yaw or tumbling. Firing of a firearm V2 is the velocity of the bullet exiting the target tissue]);
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Figure 4 Different types of bullets: From left to right; a 22 caliber non-jacketed, a 9 mm full metal jacket, a .45 ACP full metal
jacket, a 357 magnum semi-jacketed, a .45 colt semi-jacketed and an AK-47 cartridge 7.62 × 39 mm.
behavior of the bullet inside target tissue (fragmentation, and construction in relation to the wound; whereas the
deformation, yaw, tumble, or exit wound) which in turn other studies the response of live tissues to injury from
depends on bullet composition and mass; and response of projectiles.9 , 20 Many studies have described management
target tissue to the bullet which depends on composition of gunshot wounds, with relatively few studies explain-
and elasticity of target tissue (bone, muscle, liver etc.).18 ing the mechanisms of ballistic trauma, whose evidence
Table 1 gives examples of velocities and kinetic energy of is mainly based on animal and laboratory data. Most of
various bullets.18 these studies show that low velocity handgun bullets usu-
Terminal ballistics studies the effect of a projectile on ally cause localized crush injury limited to the bullet’s
target tissues.14 , 15 The term wound ballistics was coined path. High velocity rifle injuries on the other hand cause
by 2 American Military officers for a field which is a damage directly in the permanent cavity made by the bul-
part of terminal ballistics.19 It is further subdivided into let’s path as well as temporary cavity formed due to en-
2 discrete areas, one of which deals with individual prop- ergy transfer because of tumbling or deformation of the
erties of the bullet (or projectile) like mass, velocity, shape, bullet.8
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A B
C D
Figure 5 Wound profile of (A) tumbling bullet, (B) bullet being deformed in tissue, (C) fragmenting bullet (D) exploding bullet.
Table 1 Velocity and kinetic energy characteristics of various Target

guns20 surface
Temporary
Caliber Velocity Muzzle energy cavity
(ft/s) (ft-lb)
Handguns
0.25 in 810 73
0.32 in 745 140 Temporary
cavity
0.357 in 1,410 540
0.38 in 855 255
Permanent cavity
0.40 in 985 390
0.44 in 1,470 1,150
0.45 in 850 370 Figure 6 Demonstration of permanent and temporary cavities:
9 mm 935 345 Permanent cavity is ellipsoid due to bullet tumble and not per-
10 mm 1,340 425 fectly cylindrical as theoretically expected. A temporary cavity is
Long guns/military weapons created outside the path of the bullet by the shockwave of the
0.243 Winchester 3,500 1,725 bullet passing through the tissues. It can cause injuries outside
M-16 3,650 1,185 of the direct path of the bullet.
7.62 NATO 2,830 1,535
Uzi 1,500 440
AK47 3,770 1,735 in tissue. Cavitation can be temporary or permanent. Per-
manent cavitation is commonly referred to as the “bullet
track” which is formed due to crushing and displacement
Cavitation of the tissue by the bullet.18 , 22 Common thinking would
assume the permanent cavity to be cylindrical due to the
As mentioned above, tissues are injured by deposition shape of a bullet, but the permanent cavity is usually
of energy from the fired projectile which in turn depends elliptical due to yaw and tumbling of the bullet (Figure 6).
on many factors related to projectile and target tissue. The shape of the permanent cavity may further be changed
Most lethal projectiles are those that impart all their due to fragmentation of the bullet. The temporary cavity
kinetic energy into targets without exiting, hence caus- is caused by hydrostatic pressure or shock wave generated
ing the most damage. These types of missiles could be by the moving bullet which causes stretching and disrup-
tumbling bullets, expanding bullets or explosive bullets21 tion of tissues adjacent to the permanent cavity.16 , 18 , 23
(Figure 5). Cavitation is the space created by the bullet Although formation of a temporary cavity is a transient
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phenomenon, the organ injuries caused by temporary from temporary cavitation better and suffer less damage as
cavitation may be long lasting. Temporary cavities could compared to compact parenchymatous organs like liver and
be as much as 30 times larger than the projectile path.21 , 24 kidneys which have higher density and less elasticity.21 , 26
One of the popular misconceptions is to use the term Shotguns on the other hand, can produce devastating in-
“high velocity” interchangeably with “high energy” projec- juries despite being low velocity weapons. This is due to
tile. Although the kinetic energy of a projectile is mainly a larger surface area of the impact and individual pellets
determined by its velocity; “high energy” wounds are the transferring all their energy to the tissue, due to rapid de-
ones with increased wound severity and extensive tissue celeration. Moreover, due to more scattering of the pellets
damage, and the capability of a high velocity projectile inside the wound, the wounds are larger and more complex
to cause high energy wound is not solely determined by as compared to bullet wounds.9 , 32
its velocity.18 , 20 , 25 , 26 The factor that determines extent of
tissue damage is not the kinetic energy of projectile, but
how much kinetic energy is transferred to the target tis-
sue. This energy transfer is dependent on the retardation Conclusion
of the projectile by the tissue which depends on the re-
tarding force resisting the projectile’s motion. In turn, this The basic structure of firearms is similar with a stock
resisting force is a function of velocity and cross-sectional for handling, action for ignition of firearm and barrel from
area of the front of the projectile; as well as density and where the projectile leaves. On this principle, firearms have
elasticity of the tissue penetrated.9 , 20 , 27 , 28 evolved over centuries from muzzleloaders and cannons
Sectional density is the major determining factor for the where a lot of work was required by man to operate them,
amount of energy transferred from a projectile to a target to automatic weapons where all you need to do is pull the
tissue. Sectional density is the ratio of mass of the projec- trigger. With the advent of newer firearms and increased
tile to the surface area of the leading edge of the projectile availability to civilians, firearm induced trauma has become
which depends of yaw, tumble, or fragmentation of the pro- a common situation encountered by trauma surgeons. Pen-
jectile. Slowing of the projectile velocity due to resistance etrating trauma to the neck is different from the rest of the
produced by medium is calculated by drag. Drag is the body because the neck is a compact structure containing
force produced by resistance to motion of the projectile numerous vital organs. Multiple organs could be injured
and can be calculated by the following equation: from penetrating trauma which would otherwise injure a
single organ/structure in other regions of the body. Stab
CD × d × v2
Drag = wound injuries are usually straightforward, and treatment
M/A depends on the zone of the neck involved and organ in-
where CD is the coefficient of drag for the projectile; jured. Gunshot wounds on the other hand, need the sur-
d is the density of medium through which the projectile geon to be aware of the ballistics of a projectile to cor-
travels; v is the velocity of the projectile; M is the mass rectly determine the vector of the wound inside the neck
of the projectile; and A is the cross sectional area of and anticipate organ injury even if the trajectory of projec-
the projectile. Sectional density forms the denominator tile is away from that organ. Handguns fire low velocity
in this equation and hence is a major determining factor projectiles while rifles fire high velocity projectiles. This
for energy transfer from the projectile to target tissue. In determines the kinetic energy deposited in the target since
general, the higher the surface area of projectile, the lower kinetic energy is dependent on velocity. Damage induced
will be the sectional density which in turn subjects the to the tissue depends on certain other factors apart from
projectile to a relatively greater drag retarding its move- kinetic energy of the projectile. These factors include the
ment, and hence losing more kinetic energy resulting in area of the projectile head which can be changed due to
more tissue damage.14 , 18 Higher energy transfer can occur yaw or tumble, fragmentation of the projectile and density
from enlargement of the cross-sectional or presenting area of the medium. All these factors work through a common
of the projectile secondary to yaw or tumbling. Yaw is pathway of resisting the motion of the projectile which
the deviation of the projectile’s axis in relation to its relates to the amount of energy transferred and the tis-
trajectory. Yaw occurs due to overturning torque caused sue damage incurred by the projectile. Knowledge about
by the resisting force of the medium on the presenting the type of the firearm (handgun, rifle or shotgun); com-
area of the projectile.26 , 28-30 While in flight, the tendency position and structure of the bullet (jacketed, SJ, or NJ);
of a projectile to yaw is counteracted by stabilizing action effects of fragmentation, yaw and tumble of bullet; and
of the spinning motion that is imparted by the rifling mechanisms of formation of temporary and permanent cav-
of a firearm; but this is insufficient to maintain head on ities would certainly help surgeons in management of pen-
orientation in tissue due to higher density as compared to etrating trauma. Management of penetrating neck trauma
air, resulting in irreversible yaw or tumbling which in turn has evolved from nonoperative management during World
increases the presenting area of the projectile; resulting in War I to mandatory exploration in World War II to selec-
higher energy transfer and more tissue damage as the bul- tive neck exploration currently, with progressive reduction
let crushes the tissue with its lateral surface.9 , 20 , 28 , 31 More in morbidity and mortality. Wound ballistics, traditionally
elastic tissues like lung parenchyma tolerate the stretch studied by soldiers, law enforcement officials and weapon
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manufacturers are of particular interest for surgeons, as it 15. Hayes D, et al General Principles in Treating Facial, Head, and Neck
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there is nothing to disclose.
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ARTICLE IN PRESS [mUS6b;October 27, 2020;19:4]

Mechanisms of Penetrating Trauma to the Neck

Available online xxx

Introduction tremendous proportion of gun ownership relates directly

listics cannot be understated. Inappropriate management Stock

Figure 1 Parts of a basic firearm.

Metallic cartridge case

Figure 3 Examples of modern ammunition and cartridge head stamps.

Table 1 Velocity and kinetic energy characteristics of various Target

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