title: Indications for bullet removal: overview of the literature, and clinical practice guidelines for European trauma surgeons.
abstract: OBJECTIVE
  The incidence of gunshot wounds from civilian firearms is increasing. Despite this fact, guidelines on indications for bullet removal are scarce. In this analysis, we combine an overview of the available literature in these rare entities with our experiences in our own clinical practices.
  
  
  METHODS
  We conducted a systematic literature search of computerized bibliographic databases (Medline, EMBASE, and the Cochrane Central Register). The local experience of the authors was reviewed in light of the available literature.
  
  
  RESULTS
  145 full-text articles were suitable for further evaluation. Only six retrospective studies were available, and no prospective study could be retrieved. Most of the articles were case reports. In the South African co-author's own clinical practice, approximately 800 patients are treated per year with gunshot wounds.
  
  
  CONCLUSIONS
  In summary, there are only a few clear indications for bullet removal. These include bullets found in joints, CSF, or the globe of the eye. Fragments leading to impingement on a nerve or a nerve root, and bullets lying within the lumen of a vessel, resulting in a risk of ischemia or embolization, should be removed. Rare indications are lead poisoning caused by a fragment, and removal that is required for a medico-legal examination. In all other cases the indication should be critically reviewed.
authors.affiliation: Department of Orthopaedic Trauma, University of Aachen Medical Center, 30 Pauwels Street, 52074, Aachen, Germany. tdienstknecht@ukaachen.de.
authors.forename: T
authors.initials: T
authors.lastname: Dienstknecht
authors.affiliation: Department of Orthopaedic Trauma, University of Aachen Medical Center, 30 Pauwels Street, 52074, Aachen, Germany.
authors.forename: K
authors.initials: K
authors.lastname: Horst
authors.affiliation: Department of Orthopaedic Trauma, University of Aachen Medical Center, 30 Pauwels Street, 52074, Aachen, Germany.
authors.forename: R M
authors.initials: RM
authors.lastname: Sellei
authors.affiliation: Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Berner
authors.affiliation: Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Nerlich
authors.affiliation: Departments of Health KZN and Surgery, Trauma Service, University of Kwazulu-Natal, Inkosi Albert Luthuli Central Hospital, Durban, South Africa.
authors.forename: T C
authors.initials: TC
authors.lastname: Hardcastle
keywords: Bullet removal; Fragment; Gunshot wounds; Missile
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