THE MANAGEMENT OF RETAINED BULLETS IN THE LIMBS

High energy gunshot wounds are considered contaminated. Wound explorat ion and aggressive debridement are mandatory, and retained bullets sho uld be removed during this procedure. The majority of civilian gunshot wounds are of low energy, however, and the management of retained bul lets in these injuries depends primarily on the location of the missil e. In general, bullets retained in soft tissue or muscle can be observ ed, and if problematic, removed electively when the acute soft tissue swelling has subsided. Bullets that are retained in bone may be follow ed closely provided that joint violation has been excluded. The curren t authors recommend prophylactic removal, arthroscopically if possible , of all intra-articular and intra-bursal bullets in order to prevent the devastating complications of lead arthropathy and, less commonly, plumbism. If significant lead deposition already exists within the joi nt, thorough synovectomy and debridement are necessary Any joint which has been penetrated by a bullet should be considered for exploration, regardless of the bullet's final position, in order to retrieve bone, cartilage, skin, clothing, and other debris which may remain in the j oint. Removal of bullets in patients exhibiting acute lead intoxicatio n should await reduction of serum lead levels. Chelation therapy must continue postoperatively in these patients until total body lead store s have been depleted.