Pediatric air gun shot injury

Abstract

Air guns (AGs) use air or another compressed gas to propel a projectile. Different injuries may occur in children due to their body structure, which is less-resistant with thin soft tissue coverage that can be easily penetrated by an AG shot. We present 3 cases of pediatric AG shot injury. The first-case had right lumber deep tissue penetration of AG pallet without internal damage, the second-case had a complex course of pellet into the perineum, and the third-case was shot in the left shoulder. All cases were accidentally shot. The shooters were all children, and relatives of the victims. All patients were generally stable on arrival. Two cases were operated, and one received conservative management. On follow up, no complications were noted. At first sight, AGs and air rifles may appear relatively harmless, but they are potentially lethal and children should not be allowed to play with them.

Air guns (AGs) are known for their use in sporting entertainment, and so inappropriate use of these weapons often leads to serious injuries.1 In general, people think that trauma inflicted by air weapons is trivial. In fact, this is not true and the potential for serious and fatal injuries is significant.2 Here, we report 3 cases of serious AG injury in children and review the relevant legislation covering the use of air weapons. Our objective is to highlight the problem in pediatric age group and raise awareness on its harm.

Case Report

Patient One

A 10-year-old male child was referred to our Pediatric Emergency Department (ER) with an accidental AG shot injury at the right lumber region by his 11-year-old brother. The point of entry was at the right anterior lateral lumber region. The entry site was a tiny spot, clean, with a reddish margin with no bleeding or swelling. He was clinically stable. His initial assessment revealed a pellet deep into the right side lumbar region. Plain x-ray and ultrasound were carried out the pellet was visualized penetrating in the tissues and muscles in the right lumbar region below the costal margin and anterior to the vertebral line (Figure 1). The pellet was removed under fluoroscopy from the deep muscle layers. He was followed up by both the pediatric, and pediatric surgery teams and was discharged home the next day in good condition with follow-up instructions.

Figure 1.

Patient 1. Plain x-ray showing a pellet in the right lumber region.

Patient 2

A 3-year-old male child presented with AG shot injury in the right inguinal region. He was shot by his 12-year-old male relative. On assessment, he was generally stable with entry point of a pellet at the distal and lateral border of the right inguinal region with no other signs except the testis was palpable just above the point of entry (undescended testis on right side). The entry site was a tiny spot, clean, with reddish margins with no bleeding or swelling. Ultrasound, x-ray, and CT scan were carried out (Figures 2A & 2B) and revealed undamaged testis in the right inguinal side and pellet impaction deep into the perineum near the inferior ramus of the pubic bone. Surgery was planned for 2 reasons; first to remove the pellet and second to explore the right inguinal region considering 2 possibilities; either to perform orchidopexy if the testis was not traumatized, or to manage accordingly if the testis was traumatized by the pellet. The surgery was then carried out under fluoroscopy, and the pellet was removed. Right side orchidopexy was carried out in the same setting as the testis was normal. He was followed up by the pediatric and pediatric surgery teams and he was discharged without any complications.

Figure 2.

Patient 2. Three dimensional x-ray image of the pelvic region showing an impacted pellet. B) Computerized tomography scan of the perineum showing a deeply impacted pellet.

Patient 3

An 11-year-old male child was seen in the ER with an AG shot injury to the left shoulder accidentally shot by his 12-year-old brother from behind. He was in good condition. The entry point was at the postero-lateral upper part of the chest wall, which appeared as a clean tiny spot with a reddish margin with no bleeding or swelling. Plain x-ray showed a pellet deep in the muscles of the left side, near the surgical neck of the humerus (Figure 3). He was symptom free, so it was decided by both the pediatric and pediatric surgery teams to follow a conservative plan, keeping him under observation with follow up. He was discharged home in good condition without intervention.

Figure 3.

Patient 3. Air gun pellet near the surgical neck of the left humorous.

Discussion

Air gun use started back since the time of the Napoleonic wars using the expanding force of compressed air (or gas) to propel a projectile.3 The projectiles are usually lead pellets or ball bearings. Modern technology has increased the muzzle velocity and hence the penetrating power of these weapons. In a review of experimental studies, DiMaio4 concluded that the critical velocity for penetration of human skin by an AG pellet was between 38 and 70 m/sec (125±230 ft/sec). With the industrial revolution, their velocity has increased and many of them can now deliver muzzles with velocities similar to a conventional hand gun.5 Although shooting another person or the person himself is usually accidental, injuries can be serious and even fatal,1,5 with teenage boys being the usual victims;6 and usually in the absence of adult supervision. Injuries to the child’s eyes,7 head, neck, and thorax have often been published, while injury to the genitourinary area was rarely reported.8 Air guns are considered by many people as toys leading to increased incidents of AG injuries.9

In many countries, these instruments neither come under the purview of the Arms Act, nor is there is any restriction on the user’s age. Most conventional air weapons do not require a license and children less than 14 years are allowed to use an air weapon.3 Deaths have been reported in many studies due to fatal AG shots.10 This enables children to gain access freely to them from homes or markets. Approximately 2-2.5 million non-powder firearms are sold annually, and nearly 12.9 per 100,000 population are treated for such injuries in the United States per year.6

Although only a few cases of AG injuries in the children and their severe impact on different sites were reported, we believe this is due to under reporting. We presented 3 cases from a single center from a single district in Saudi Arabia to highlight the issue and raise a red flag for the seriousness of AG use, especially by children. We believe that solving the issue of AG injuries requires integrated cooperation between the governments and their nations. Governments should issue strict laws, and regulations for AG use. A punishment hard enough to prevent people dealing with these weapons as toys should be issued to deter people from using these weapons and harming others even accidentally. The mass media should play their intended role in educating people and raising their awareness of AGs and their potential catastrophic sequelae. An actual and really important part is the self-sense of responsibility of people towards caring for the lives of others. Education, integration, and love are the golden keys to prevent humans from harming each other in every single aspect; one of these is AG injuries!

Ethical Consent.

All manuscripts reporting the results of experimental investigations involving human subjects should include a statement confirming that informed consent was obtained from each subject or subject’s guardian, after receiving approval of the experimental protocol by a local human ethics committee, or institutional review board. When reporting experiments on animals, authors should indicate whether the institutional and national guide for the care and use of laboratory animals was followed.