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The odd or even bullet
162
The Journal of Emergency Medicine
hospital setting. [Kim S. Friedman, MD] Editor’s Note: An intriguing use which the authors suggest is that of prehospital blood typing of trauma patients by paramedical personnel. Type-specific blood could then be available for the patient upon arrival at the emergency department. Cl PELVIC PLAIN
FRACTURES:
RADIOGRAPHY
IN
VALUE
OF
EARLY
AS-
Young SESSMENT AND MANAGEMENT. JWR, Burgess AR, Brumback RJ, et al. Radiology 1986; 160:445-451. The authors retrospectively reviewed the plain radiographs of 142 patients with pelvic fractures who presented to the Maryland Institute of Emergency Medical Services. Four distinct patterns of force were identified: anteroposterior (AP) compression (15% of cases), lateral compression (57Oro), vertical sheer (6Oro), and complex fractures (22%). AP compression fractures could be distinguished from lateral compression in that pubic rami fractures were vertically oriented in the former and horizontally oriented in the latter. AP compression frequently produces fractures of the pubic ramus and may cause ligamentous injury involving the ligaments of the symphysis, the anterior and posterior sacroiliac ligaments, and the sacrospinous and sacrotuberous ligaments. Lateral compression fractures were the most common and usually involve fractures of the pubic rami (loo%), sacrum (88%), and iliac wing (19%). Ligamentous disruption may be minimal. Verticle sheer injuries result from falls or falling objects and the sacrum is driven between the pelvic wings with severe ligamentous disruption. Complex pattern fractures had lateral compression as the predominant force in over 75% of the cases reviewed. The authors found that the vast majority of diagnoses could be made by using the AP radiograph alone (94% of cases in this series). Computed tomography was more accurate for evaluating the acetabular joints and the SI joints, but should be reserved for patients who were hemodynamically stable or in whom a more detailed view of the pelvis was required for definitive surgery. The authors conclude that appreciation of the types of pelvic fracture, direction of the forces producing them, and likely ligamentous injuries can be achieved rapidly and inexpensively from plain radiographs, indicating the type of disruptive force and guid-
ing the dure.
planning
of the corrective proce[Nicholas J. Jouriles]
0 THE ODD OR EVEN BULLET. Westreich M. Znjury 1986; 17:45-46. Low velocity bullets do not always course through the body in a straight path and are frequently found in strange places. If all bullets are not accounted for during the primary evaluation, serious injuries may be missed. The authors describe a simple rule to help account for the number of bullets present in the body of a victim of low velocity gunshot wounds. The rule is “if the number of bullet holes (both entrance and exit) is odd (or even), then the number of bullets remaining in the patient is odd (or even) as well.” Zero is considered an even number. Two cases are presented in which serious vascular injury may have been missed had this rule not been used and a search undertaken for the missing bullet. The authors note several exceptions to the “odd-even” rule including: (1) a bullet hole in a body crease may be a tangential injury and represent both entrance and exit wounds, (2) bullets may have hidden entrance or exit wounds, notably in the natural orifices, and (3) bullet wounds with their surrounding tissue destruction may be so large that it is impossible to determine if more than one bullet entered or left at that point. The authors conclude that familiarity with this simple rule will be helpful to the physician confronted with managing civilian gunshot wounds in accurately determining the extent of injury. [David C. Stastny, DO] Editor’s Note: Although the odd-even rule seems rather simple and self evident, consistent and systematic application of the principle to all gunshot wound injuries may help the emergency physician avoid the embarrassing situation of “late bullet discovery.”
0 ELECTRICAL ACCIDENTS DURING PREGNANCY. Leiberman JR, Mazor M, Molcho J, et al. Obstet-Gynecol. 1986; 67:861863. A report of six patients receiving minor electrical shocks during pregnancy is presented and the literature reviewed. All six patients suffered electrical shocks at home; gestational age ranged from 21 to 40 weeks. There was no loss of consciousness, no cutaneous wounds, and
The Journal of Emergency Medicine
hospital setting. [Kim S. Friedman, MD] Editor’s Note: An intriguing use which the authors suggest is that of prehospital blood typing of trauma patients by paramedical personnel. Type-specific blood could then be available for the patient upon arrival at the emergency department. Cl PELVIC PLAIN
FRACTURES:
RADIOGRAPHY
IN
VALUE
OF
EARLY
AS-
Young SESSMENT AND MANAGEMENT. JWR, Burgess AR, Brumback RJ, et al. Radiology 1986; 160:445-451. The authors retrospectively reviewed the plain radiographs of 142 patients with pelvic fractures who presented to the Maryland Institute of Emergency Medical Services. Four distinct patterns of force were identified: anteroposterior (AP) compression (15% of cases), lateral compression (57Oro), vertical sheer (6Oro), and complex fractures (22%). AP compression fractures could be distinguished from lateral compression in that pubic rami fractures were vertically oriented in the former and horizontally oriented in the latter. AP compression frequently produces fractures of the pubic ramus and may cause ligamentous injury involving the ligaments of the symphysis, the anterior and posterior sacroiliac ligaments, and the sacrospinous and sacrotuberous ligaments. Lateral compression fractures were the most common and usually involve fractures of the pubic rami (loo%), sacrum (88%), and iliac wing (19%). Ligamentous disruption may be minimal. Verticle sheer injuries result from falls or falling objects and the sacrum is driven between the pelvic wings with severe ligamentous disruption. Complex pattern fractures had lateral compression as the predominant force in over 75% of the cases reviewed. The authors found that the vast majority of diagnoses could be made by using the AP radiograph alone (94% of cases in this series). Computed tomography was more accurate for evaluating the acetabular joints and the SI joints, but should be reserved for patients who were hemodynamically stable or in whom a more detailed view of the pelvis was required for definitive surgery. The authors conclude that appreciation of the types of pelvic fracture, direction of the forces producing them, and likely ligamentous injuries can be achieved rapidly and inexpensively from plain radiographs, indicating the type of disruptive force and guid-
ing the dure.
planning
of the corrective proce[Nicholas J. Jouriles]
0 THE ODD OR EVEN BULLET. Westreich M. Znjury 1986; 17:45-46. Low velocity bullets do not always course through the body in a straight path and are frequently found in strange places. If all bullets are not accounted for during the primary evaluation, serious injuries may be missed. The authors describe a simple rule to help account for the number of bullets present in the body of a victim of low velocity gunshot wounds. The rule is “if the number of bullet holes (both entrance and exit) is odd (or even), then the number of bullets remaining in the patient is odd (or even) as well.” Zero is considered an even number. Two cases are presented in which serious vascular injury may have been missed had this rule not been used and a search undertaken for the missing bullet. The authors note several exceptions to the “odd-even” rule including: (1) a bullet hole in a body crease may be a tangential injury and represent both entrance and exit wounds, (2) bullets may have hidden entrance or exit wounds, notably in the natural orifices, and (3) bullet wounds with their surrounding tissue destruction may be so large that it is impossible to determine if more than one bullet entered or left at that point. The authors conclude that familiarity with this simple rule will be helpful to the physician confronted with managing civilian gunshot wounds in accurately determining the extent of injury. [David C. Stastny, DO] Editor’s Note: Although the odd-even rule seems rather simple and self evident, consistent and systematic application of the principle to all gunshot wound injuries may help the emergency physician avoid the embarrassing situation of “late bullet discovery.”
0 ELECTRICAL ACCIDENTS DURING PREGNANCY. Leiberman JR, Mazor M, Molcho J, et al. Obstet-Gynecol. 1986; 67:861863. A report of six patients receiving minor electrical shocks during pregnancy is presented and the literature reviewed. All six patients suffered electrical shocks at home; gestational age ranged from 21 to 40 weeks. There was no loss of consciousness, no cutaneous wounds, and