One bullet, five compartments: a transregional gunshot trajectory and the limits of operative intervention

Achoimre

Abstract Gunshot wounds with transregional bullet trajectories present significant diagnostic and management challenges. We report the case of an 20-year-old male who sustained a single gunshot wound entering at the left angle of the mandible, traversing the neck with injury to the thyroid cartilage, ricocheting off the right sternoclavicular joint and tracking through the right lung causing haemopneumothorax, before lodging in the perinephric fat adjacent to the right kidney. Pan-scan computed tomography (CT) was pivotal in delineating this complex trajectory. Management required a multidisciplinary approach involving Head & Neck surgery, Trauma surgery, Cardiothoracics, and Intensive Care. Diagnostic laparoscopy confirmed no peritoneal breach, supporting selective non-operative management (SNOM) of the retroperitoneal bullet. This case highlights the importance of thorough CT imaging from head to pelvis, the safety of SNOM for retroperitoneal bullets in stable patients, and the necessity of coordinated multidisciplinary surgical care for managing complex transregional gunshot injuries.