Page 81 - JSOM Summer 2025

depth of 1cm, no steel shrapnel was found. I discussed my plan Calling my medical director early and opening my initial plan
with my medical director and made the decision to evacuate to refinement was a helpful decision that I would repeat in the
my patient. I continued a course of antibiotics with cephalexin future. My presence from the point of injury to evacuation,
500mg every 12 hours for 7 days. During this time, I reassessed surgery, and through recovery for my patient was insightful
my teammate for calor at the wound site, rubor, and tumor and eye opening. It was a lesson that I will carry with me for
expanding around the knee and monitored his temperature the rest of my career in medicine, applying the same advocacy
to ensure he wasn’t becoming febrile. Upon administering the and care for future patients.
Lachman test and the anterior drawer test, I noted no laxity or
structural damage, though these tests can be falsely negative in Acknowledgments
the acute phase following an injury. While the wound showed The authors thank the Special Operations Forces to School of
1
no signs of infection, I evacuated my teammate to Germany Medicine (SOFtoSOM) Editorial Board for their support of
with our main body approximately 3 days after the incident this work.
due to concern for intra-articular involvement.
Author Contributions
DC and MAB conceptualized the paper and drafted the man-
Role 4
uscript. Critical revision and editing were performed by IRM,
I scheduled an appointment at Landstuhl Regional Medical MS, RMD, and REB. All authors read and approved the final
Center upon landing in Germany. Before our appointment, manuscript.
my teammate mentioned feeling a sharp pain when bending
his knee. In addition to writing a medical note, I contacted Disclosures
my medical director, a trauma surgeon, and a sports-focused RMD is a peer reviewer for the Journal of Special Operations
physical therapist to discuss outcomes for similar patients. Al- Medicine.
though this fragment would not necessarily be removed in the
civilian practice setting, I advocated for surgery, knowing that Disclaimer
my teammate needed knee flexion for functional movement in Opinions or assertions contained herein are the private views
his job as well as concern for long-term complications. Knee of the authors and are not to be construed as official or as
2–4
radiographs identified a 3-cm piece of shrapnel within his left reflecting the views of the Department of the Army, or the De-
knee joint capsule. The Landstuhl team scheduled surgery to partment of Defense.
remove the shrapnel, and I assisted the Certified Registered
Nurse Anesthetist in airway management. My teammate made Funding
a full recovery, remained with us for the duration of the de- No funding was received for this work.
ployment, and healed well without residual left knee issues.
References
Lessons Learned: 1. Thomas M, Mumith A, Ghani Y. Imaging of foreign bodies: a radio-
1. Having a plan to irrigate and manage possible infection. logical conundrum. BMJ Case Rep. 2017;2017:bcr2017219706.
2. Calling my medical director early. doi:10.1136/bcr-2017-219706
3. Using my tools in a novel application. 2. DeMartini J, Wilson A, Powell JS, Powell CS. Lead arthropathy
and systemic lead poisoning from an intraarticular bullet. AJR Am
J Roentgenol. 2001;176(5):1144. doi:10.2214/ajr.176.5.1761144
Conclusion 3. Farber JM, Rafii M, Schwartz D. Lead arthropathy and elevated
serum levels of lead after a gunshot wound of the shoulder. AJR
After this incident, I sought to learn a less invasive procedure Am J Roentgenol. 1994;162(2):385–386. doi:10.2214/ajr.162.2.
to identify shrapnel. In learning about the benefits of using 8310931
ultrasonography, I underwent additional ultrasound training 4. Long B, April MD. Are patients with retained bullet fragments
at greater risk for elevated blood lead levels? Ann Emerg Med.
to prevent complication in future care, including infections as 2020;75(3):365–367. doi:10.1016/j.annemergmed.2019.10.010
well as long-term complications including lead arthropathy 5. Tantray MD, Rather A, Manaan Q, Andleeb I, Mohammad M, Gull
and lead poisoning. I had ultrasound training and the tools Y. Role of ultrasound in detection of radiolucent foreign bodies in
1,5
to identify the shrapnel, but I did not use them in the manage- extremities. Strategies Trauma Limb Reconstr. 2018;13(2):81–85.
ment of this patient. Ultrasonography would have identified doi:10.1007/s11751-018-0308-z
the steel shrapnel earlier, expedited the evacuation process, 6. Aras MH, Miloglu O, Barutcugil C, Kantarci M, Ozcan E, Harorli
and reduced the risk of infection associated with wound A. Comparison of the sensitivity for detecting foreign bodies
among conventional plain radiography, computed tomography
exploration. and ultrasonography. Dentomaxillofac Radiol. 2010;39(2):72–78.
doi:10.1259/dmfr/68589458
In continuing to read articles on how ultrasound machines are
used in low-resource environments, I am better prepared to PMID: 40549888; DOI: 10.55460/151S-HWT9
maximize my tools; given the higher sensitivity of ultrasonog-
raphy to identify metallic foreign bodies when compared with
CT scanning, comfort and facility with ultrasonography can
pay huge dividends in austere deployment locations. 6

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