Severe Craniofacial Morbidity from a Bean Bag Projectile.

Bean bag munitions, less-lethal weapons primarily used by law enforcement, can cause severe morbidity. Although bean bag munitions are less likely to cause severe injury when compared with regular gunshot rounds, it is crucial to understand that bean bag munitions may be life-threatening. In this case, we describe our experience with a patient who suffered a zygomaticomaxillary complex fracture, facial nerve injury, and retained munition round in his maxillary sinus from a bean bag projectile shot during an altercation with the police. The patient was urgently transferred to the operating room for extraction of the bean bag munition, and although fracture repair was successful, the patient sustained significant damage to facial nerves, leading to lagophthalmos. To our knowledge, this is the first case report describing a penetrating injury from a bean bag munition that was retained within a facial structure. We will discuss the surgical intervention used for this patient and the review of the current literature on these less-lethal munitions.

INTRODUCTION

Bean bag munitions are thought to be safer alternatives for crowd control because they deliver less force than standard munition rounds. The basic composition of a bean bag is a synthetic bag filled with lead pellets that is fired from a shotgun.[1] Although bean bag munitions are less likely to cause severe injury when compared with standard ones, it is crucial to become aware that bean bag munitions may be life-threatening.[2] The current literature has reported severe injuries such as thoracic damage,[3] epidural hematomas,[4] and penetrating ocular traumas.[5] In this article, we describe our experience with a patient who suffered a zygomaticomaxillary complex fracture, facial nerve injury, and retained munition round in maxillary sinus from a bean bag projectile.

CASE DESCRIPTION

A 35-year-old man with no significant prior medical history presented to the emergency department (ED) after being shot in the face with a bean bag munition during an altercation with law enforcement (Fig. 1). Upon arrival to the ED, the patient’s Glasgow Coma Scale was 13. He was too agitated to undergo a formal motor and sensory examination of his facial structures, to cooperate with his care, and soon became a risk for himself and others. As a result, he was given antipsychotics, ketamine, and was eventually intubated to manage his uninhibited agitation. He was then evaluated in the emergency room with computed tomography (CT) of the brain, face, and cervical spine (Fig. 2). These revealed a left zygomaticomaxillary complex fracture with a retained foreign body in the left maxillary sinus, a frontal calvarium and sphenoid fractures, proptosis of left globe with displaced osseus fragment contacting the left lateral rectus muscles, and a small frontal intracerebral hemorrhage. On ophthalmological examination, he was found to have elevated left globe intraocular pressure (IOP) measuring 47 and 54 on a repeat read, and had no evidence of pupil peaking, vitreous hemorrhage, retrobulbar hemorrhage, or retinal detachment. Due to the elevated IOP, a lateral canthotomy was performed by the Ophthalmology team. Following the canthotomy, the IOP was decreased to 17. The frontal intracerebral hemorrhage was stable at a 6-hour repeat head CT, and as a result, no further management or surgical interventions were recommended by the Neurosurgery team. He was then transferred to the surgical intensive care unit for ventilation management and pain control.

Fig. 1.

External appearance of the patient’s injury upon initial presentation. On digital examination of the wound, a depth of approximately 4cm was palpated.

Fig. 2.

Coronal view of the patient’s CT scan, which showcases the facial fractures upon initial presentation. A foreign body is visible in the left maxillary sinus, and a zygomaticomaxillary complex fracture is noted.

Eight hours after his initial presentation to the ED, he was taken to the operating room for surgical removal of the foreign object retained in his maxillary sinus, and for open reduction and internal fixation of his zygomaticomaxillary complex fracture. The first step in the operation was to retrieve the foreign body through the open wound created by the initial impact from the munition on the left side of his face. The bean bag munition that was removed from his left maxillary sinus can be seen in Figure 3. Upon removal of the bean bag, the fracture sites were exposed through the infraorbital mid lid, eyebrow, and intraoral vestibular approaches. A 3-point fixation was performed at the zygomaticofrontal junction, infraorbital rim, and zygomaticomaxillary buttress (Fig. 4). Although attempts were made, no responsive branches of the facial nerve were found in the region. The procedure was completed successfully, and the patient was discharged without complications 4 days after presentation.

Fig. 3.

Bean bag munition extracted from the patient’s left maxillary sinus.

Fig. 4.

3D CT reconstruction of the patient’s facial bones following the removal of the bean bag, and open reduction internal fixation of the zygomaticomaxillary complex fractures.

DISCUSSION

Bean bag munitions are considered to be less-harmful munitions, and are used by law enforcement agencies for crowd control in all 50 states.[1] Moreover, the use of these projectiles has also been documented in Europe, Southeast Asia, and Northeast Asia.[6] Despite widespread use of bean bag munitions, there is a lack of literature describing the potential impact of these “less-lethal” munitions. A 2004 report by the National Institute of Justice describing 373 injuries caused by less-lethal munitions documented in police reports is the most inclusive report to date.[7] Bean bag munitions were a staggering 65% of these injuries, and the number of injuries has likely increased significantly in recent years given law enforcement’s preference for these weapons for crowd control and civil unrest.

Although these munitions are designed to inflict superficial painful injuries, a wide range of serious penetrating injuries have been reported.[1-3,5] The standard model is a 5 × 5 bean bag filled with led pellets, shot from a 12-gauge-shot-gun with a velocity of approximately 90 m/s.[8] Though law enforcement agencies train officers to shoot from 30-feet away, there is more accuracy and greater resulting injuries from shorter distances.[7] Additionally, due to bean bag munitions’ lower velocity compared with traditional gun shot rounds, they can be a significant source of infection and immediate surgical removal is often warranted.[9,10]

Of the cases reported in the literature, there are few reports of facial and ocular trauma from a bean bag injury.[5] To our knowledge, this is the first case report describing a penetrating foreign body that was retained within a sinus. In this case, the patient suffered a penetrating shot through the left maxillary sinus, leading to a comminuted zygomaticomaxillary complex fracture and facial nerve damage. Although the urgent surgical removal of the bean bag and fixation of facial fractures was successful, the injury to his facial nerve now requires the placement of an upper eyelid weighted implant for the treatment of the significant lagophthalmos he developed.

CONCLUSIONS

Although bean bag munitions are described as “non-lethal” and have reduced morbidity and mortality compared with traditional gun shot rounds, there have been a number of reports of serious injury and death caused by these weapons. In this study, we described the serious maxillofacial injuries that can be caused by bean bag munitions, and the crucial role that plastic surgeons may play in the management of complex facial fractures in such cases. Additional studies are needed to further evaluate the safety of bean bag munitions used as means for crowd control.

PATIENT CONSENT

The patient provided written consent for the use of his image.