Penetrating Ocular Trauma from a Bean Bag Gun: A Case Report and Review of Less-Lethal Force and Their Consequences

Abstract

Although bean bag guns are considered a “less-lethal” form of law enforcement, these blunt projectiles have risk. The purpose of this study was to perform a literature review of morbidity and mortality associated with less-lethal munitions and present a case report of a bean bag injury leading to a traumatic globe evisceration and skull base fracture. Patients presenting with bean bag gun associated injuries warrant a high clinical suspicion for injury to deeper structures.

Introduction

The bean bag gun is considered a “less-lethal” weapon used primarily by law enforcement agents (often in riot situations) as an alternative to lethal methods of protection. (See Figure 1.) Although many manufacturers produce different versions of this blunt projectile, the basic composition includes a sturdy fabric encasement filled with small diameter lead shot that is loaded into a shotgun cartridge and fired from a 12-gauge shotgun¹. The intended usage of the bean bag gun is to render the offending party into a controllable state without causing life threatening or permanent sequalae.

Figure 1.

Less-Lethal Close Quarters Combat Shot Gun by Wilsoncombat.com

Case Report

In our case, the patient presented to the emergency room after being shot in the eye by the blunt projectile. The patient described instant vision loss and severe right-sided facial pain. He was evaluated in the emergency room with computed tomography of the head and facial bones. This revealed a 3cm hyperintense mass that had traversed through the right orbit, fractured the superior, medial, and inferior orbital walls, the ethmoid air cells, the greater wing of the sphenoid, both anterior and posterior tables of the frontal bone as well as cribiform plate as seen in Figure 2. Beyond these injuries, it was difficult to assess further osseous injury given the significant artifact created by the lead shot. Considering the proximity of the retained foreign body to the cavernous carotid artery, the decision was made to perform a formal angiography to better assess the risk of arterial rupture during surgery. The angiogram did not show obvious damage to the internal carotid system and at that time, given risk of prolonged lead exposure and infection, the decision was made to proceed to the operating room for wound exploration and extraction of foreign body. Options for extraction of the foreign body within the sphenoid sinus region included a transnasal endoscopic approach, transorbital, lateral rhinotomy, or midface degloving.

Figure 2.

An axial CT scan at the level of the sphenoid sinus showing the projectile lodged against the anterior skull base in the nasopharynx.

Surgical Technique

Under general anesthesia, the patient was prepared for standard endoscopic sinus surgery setup with an additional field created over the right lateral thigh for emergent muscle patch should carotid bleeding have been encountered. During nasal endoscopy, significant narrowing of the nasal passage was seen due to swelling, septal deviation (towards the side of the foreign body), and significantly comminuted fractures of the lateral nasal wall/ medial wall of the orbit. The decision was made to perform an endoscopic septoplasty, right middle turbinectomy, and inferior turbinoplasty in order to create a passageway for the projectile to be removed. Using slow and steady traction, the foreign body was able to be removed through the ipsilateral nostril as seen in Figure 3. After removal of the foreign body, orbital contents were identified within the nasal cavity, including avulsed eyelid skin with eyelashes still attached. After the extraction, the patient also underwent an attempted enucleation of the remainder of the right globe with closure of complex right lower eyelid. The tattered eyelid found in the nasal cavity was non-viable and thus unable to be incorporated into the closure.

Figure 3.

The bean bag after removal from nasopharynx via an endoscopic approach.

Discussion

Less lethal ballistics have become an alternative to traditional bullets amongst law enforcement for crowd control and rioting. These have ranged from batons, to stun guns, to blunt projectiles including rubber bullets, paint balls, and bean bags. Blunt projectiles have continued to blossom over the past several decades. However, little research has been done on the sequelae from this less lethal munition.

Less lethal law enforcement has become an acceptable alternative to subdue suspects. Throughout the literature there have been case reports and case series looking at sequelae of this form of crowd control^1–4. In 2004, the National Institute of Justice published the impact of less lethal munitions. There publication is the most inclusive to date, reviewing 373 injuries, caused by all less lethal munitions. They note that bean bag munitions comprised 65% of all injuries. In their study, they note eight deaths, one linked to a penetrating neck wound. The remainder of the deaths were from thoracic injuries.⁵ Prior to our case, there was only one previously published case of orbital trauma from a bean bag injury, however in this case the bean bag and the casing did not separate and both were removed from the orbit. However, to our knowledge, to date there is no reported penetrating ocular trauma involving only the bean bag munition. The injuries described in the past include contusions, hematomas, abrasions and penetrating injuries. The most common location of injury is the thorax. The overall rate of injury to the head and neck from all previously published research is 2–3%, as detailed in Table 1.

Table 1:

Literature reporting injury^* from less-lethal munitions

	Total No. of injuries	No. of fatalities	No. of retained projectiles	No. of head/neck injuries	No. of orbital injuries
Sehgal and Challoner 1997	3	0	1	0	0
de Brito et al 2001	69	1	7	5 (7%)	1
Grange et al 2002	4	0	3	0	0
National Institute of Justice 2004***	373	8	NA	2%	0
Dojcinovic et al 2007**	1	0	1	1	0
Current case 2014	1	0	1	1	1

^*injury=additional injury outside of contusions, hematomas, or abrasions

^**Dojcinovic case was a FN303 paintball ballistic rather than a bean bag (1–4)

^***NIJ reports all non-lethal ammunition 65% reported is bean bag, 1 of the deaths from injury to the head and neck

In this case, during a period of civil unrest, the patient suffered a penetrating shot through the globe leading to enucleation of the eye, fractures of the globe, and skull base. The patient went urgently to the operating room with ophthalmology for formal enucleation of the globe. Further discussions were had with law enforcement, the material within the bean bag was lead and the decision was made to go for formal extraction of the bean bag with closure of cerebrospinal fluid leak.

This case shows that even non-lethal munition can have severe morbidity associated with their use. As a clinician, one must have a heightened awareness of the significant injuries that can be associated with this type of munition and complete an extensive physical exam to rule out any other associated injuries that are not uncommonly seen with this type of non-fatal law enforcement.

Biography

Daniel Wehrmann, MD, (above), Jastin Antisdel, MD, MSMA member since 2016, Scott Walen, MD, and Joseph Brunworth, MD, are in the Department of Otolaryngology-Head and Neck Surgery at Saint Louis University.

Contact: wehrmadj@slu.edu