Along with all other possibilities of accidental gunshot injuries, it is usually seen that gunshot firing to the knee may be done with an intention or as a criminal punishment. These may be a result of limb punishment shooting, in which injuries are inflicted by defense personnel or the armed men as a warning to the criminals or those involved in a particular criminal activity or to persons exhibiting unacceptable behavior.
The knee; particularly the knee joint is the most important weight bearing joint located at a very strategic place in the human body. It comprises an entire set of important structures like bone, soft tissues, muscles, ligaments, cartilages, nerves and vascular structures. Due to its location and structure, gunshot wound to the knee can be very painful.
Knee Injuries Caused By Gunshot
Type and extent of knee injury in most cases, depends on the position of the victim, type of weapon and the number of bullets fired. Moreover, especially in case of gunshot wounds to the knee, it is necessary to understand the situation in which the bullet was fired; accidental or intentional firing.
In an intentional firing, the bullet is mostly fired to the knee pit (the pit at the back of knee joint) with a low velocity weapon. This type of wound is called kneecapping, although only a few patients may actually have their kneecaps injured or fractured.
In the gunshot wound, the bullet penetrates into the body by crushing the tissues on its way. In case of knee joints, owing to the availability of bony structures, the penetrating bullet can cause much damage to the bone and surrounding structures leading to severe pain. The injuries mainly arise from crushing of bone and soft tissue, cavitation as well as laceration injuries to other structures.
Gunshot wound to the knee joint can cause varying degrees of damage that can include soft tissue injuries to the muscles, ligaments, cartilages and related structures supporting the knee joint, fracture of knee joint, damage to the vascular structures and in some cases, injury to the nerves in the area. Some injuries to the knee joint may involve the patella and articular surfaces of the bones.
Along with the injuries, chances of infection are high, which may be crucial in determining the functioning of the knee joint. Bullets lodged inside the knee joint are capable of producing damage to the joint, surrounding tissues and even affect circulation. Retained bullet can cause foreign body reaction, articular damage, synovitis and resulting arthritis of the joint. The synovial fluid in the knee joint has the capacity to degrade lead bullets, which can lead to systemic absorption and effects of lead poisoning or lead intoxication. The clinical picture of lead intoxication include headache, abdominal discomfort and other vague symptoms.
Treatment Of Penetrating Knee Injury Due To Gunshot
An initial assessment of the patient is performed to find the patient’s condition and the type of injuries sustained. In case, the patient needs to be stabilized, appropriate measures are taken. A thorough examination is done to identify noticeable injuries around the knee area. Additional injuries to other extremities like ankles, elbows or to any other part of the body are also assessed.
Investigations like bone radiographs and other imaging studies help to determine bone injuries. Although some soft tissues injuries may not be identified on plain radiographs and may require additional investigations and procedures. CT scans, MRI may be performed to detect bone and soft tissue details. Operative procedures may be required, in which case, arthroscopy may be effectively and safely performed for effective management of these injuries.
As the risk of infection is high, appropriate treatment is initiated. Proper wound management is essential to reduce the occurrence of infection and other complications. Wounds may require surgical debridement and arthroscopic procedure should be considered. Any foreign bodies or bullet fragments lodged inside are removed; also bones may fragment to leave loose pieces, which have to be removed. While bullet dislodgement may be rare, the urgent removal should be performed to avoid complication and lead intoxication. Arthroscopic removal of the bullet fragments is useful in preventing complications and infection.
Septic knee joints may require drainage and appropriate treatment. Injured or infected knee joints that undergo surgery need proper rehabilitation to improve the functional outcomes. Active mobilization after surgical repairs and drainage can help in regaining normal movement of the joint after recovery. Fractured knee joints are treated depending on the severity and followed by rehabilitation including physiotherapy and occupational therapy.
Leg amputation may be required in severe cases of knee injury. Associated gunshot wounds to other parts of the body may complicate the patient’s condition and cause a delay in recovery. Another important factor is the injury to vital blood vessels and nerves. Any injury to main blood vessels can affect the circulation and influences the recovery of the knee joint and nerve injury can cause permanent disability, which needs to be considered during treatment and rehabilitation.
- American Academy of Orthopaedic Surgeons (AAOS). (2019). Gunshot Wounds to the Extremities. OrthoInfo. Retrieved from https://orthoinfo.aaos.org/en/diseases–conditions/gunshot-wounds-to-the-extremities/
- Renninger, C. H., Renninger, S. F., Mullenix, J., & Zonies, D. (2017). Gunshot Wounds: Ballistics, Wound Ballistics, and Soft Tissue Management. Current Reviews in Musculoskeletal Medicine, 10(3), 346-355. doi:10.1007/s12178-017-9415-8
- Ahmed, S. S., Ahmed, A. M., & Jansen, J. O. (2019). Ballistics for Surgeons: A Review of Common Projectile Types, Ballistic Injury Patterns, and Current Practices in Wound Management. Injury, 50(8), 1351-1358. doi:10.1016/j.injury.2019.05.033
- Kheirabadi, B. S. (2018). Ballistics and Gunshot Wounds: Effects on Musculoskeletal Tissues. Journal of Surgical Orthopaedic Advances, 27(1), 38-43. PMID: 29618847