Unexpected multiple intra-abdominal injuries after projectile fragmentation: report of three cases

Background: Explosives create and energize particles that act as projectiles prone to further fragmentation, creating secondary missiles in the body, and may result in secondary injuries. We report this process for abdominal injuries after fascial penetration in the military setting.
Patients and Methods: Observational case series study. Local wound exploration was performed in conscious patients who sustained abdominal wall injuries. An intraperitoneal injury was assumed in those with a full thickness fascial defect, and laparotomy was performed.
Results: Twenty patients met the study eligibility criteria. Out of those 20 patients, 12 had negative wound exploration and were excluded from the study, while abdominal organ injuries were found in eight (40%) patients. During laparotomy, projectile-induced injuries in a sprayed distribution were found in three (38%) of these patients. Injuries were far from the predictable trajectory. The overall mean number of peritoneal defects was 1.7, and a mean of 6.8 intra-abdominal injuries for each peritoneal defect were found when through and through injuries were excluded.
Conclusions: Despite a single peritoneal defect, there may be multiple intraperitoneal injuries due to further fragmentation of the projectile. Under mass casualties, wound exploration with a full thickness fascial defect could serve as an indicator of possible intra-abdominal injuries, indicating exploratory laparotomy.