Skeletal Sarcoma on the Site of Retained War Bullet Fragments and a Literature Review on Long-Term Complications of Retained War Shells

Document Type : CASE REPORT


1 Orthopedic Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Ahmad-Abad Street Mashhad, 91799-9199 Iran.

2 Department of Orthopedic Surgery, Mehr Hospital Koohsangi Street, Mashhad, 91799-9199 Iran.

3 Department of Orthopedic Surgery, Georgia Regents University, Augusta, GA, USA.


Long-term complications of retained war fragments in the body are not completely known. Also, bullet migration and slow resorption of metals and distortion in some imaging modalities are frequent and well recognized complications but, now we are concerned about neoplastic changes near the retained war fragments.
We reviewed the literature on complication of retained war fragments and report our 2 cases of malignant changes around old retained war fragments in the limbs.


  1. Arasil E, Taşçioğlu AO. Spontaneous migration of an intracranial bullet to the cervical spinal canal causing Lhermitte’s sign. Case report. J Neurosurg. 1982;56(1):158-9.

  2. Salti IS, Haddad FS, Amiri ZN, Khalil AA, Akar AA. Bullet injury to the pituitary gland: a rare cause of panhypopituitarism. J Neurol Neurosurg Psychiatry. 1979;42(10):955-9.

  3. Kuijlen JM, Herpers MJ, Beuls EA. Neurogenic claudication, a delayed complication of a retained bullet. Spine (Phila Pa 1976). 1997;22(8):910-4.

  4. Atac K, Ulas UH, Erdogant E, Gokcil Z. Foot drop due to cranial gunshot wound. Mil Med. 2004;169(7):568-9.

  5. Isiklar ZU, Lindsey RW. Gunshot wounds to the spine. Injury. 1998;29:7-12.

  6. Link MJ, Driscoll CL, Esquenazi Y. Vagoglossopharyngeal-associated syncope due to a retained bullet in the jugular foramen. Skull Base. 2010;20(2):105-9.

  7. Mincheff TV. Bullet fragment within the appendix: a case report. J S C Med Assoc. 2004;100(10):270-3.

  8. Hørby-Petersen J, Kristiansen T, Jelnes R. Acute appendicitis caused by metallic foreign body (bullet). Case report. Acta Chir Scand. 1987;153(11-12):697-8.

  9. Kamona A, Mansour A, Qandeel M, Al-Eshaiker M. Biliary obstruction secondary to combat-related foreign bodies: report of two cases. Abdom Imaging. 2005;30(6):748-9.

  10. Van Arsdell GS, Razzouk AJ, Fandrich BL, Shakudo M, Schmidt CA. Bullet fragment venous embolus to the heart: case report. J Trauma. 1991;31(1):137-9.

  11. Hughes BD, Vender JR. Delayed lead pulmonary emboli after a gunshot wound to the head. Case report. J Neurosurg. 2006;105:233-4.

  12. Moon E, Kondrashov D, Hannibal M, Hsu K, Zucherman J. Gunshot wounds to the spine: literature review and report on a migratory intrathecal bullet. Am J Orthop (Belle Mead NJ). 2008;37(3):E47-51.

  13. Wasserman SM, Cohen JA. Spontaneous migration of an intracranial bullet fragment. Mt Sinai J Med. 1979;46(5):512-5.

  14. Akhtar AJ, Funnyé AS, Akanno J. Gunshot-induced plumbism in an adult male. J Natl Med Assoc. 2003;95(10):986-90.

  15. McQuirter JL, Rothenberg SJ, Dinkins GA, Manalo M, Kondrashov V, Todd AC. The effects of retained lead bullets on body lead burden. J Trauma. 2001;50(5):892-9.

  16. Raymond LW, Ford MD, Porter WG, Saxe JS, Ullrich CG. Maternal-fetal lead poisoning from a 15- Vear-old bullet. J Matern Fetal Neonatal Med. 2002;11(1):63-6.

  17. Scuderi GJ, Vaccaro AR, Fitzhenry LN, Greenberg S, Eismont F. Long-term clinical manifestations of retained bullet fragments within the intervertebral disk space. J Spinal Disord Tech. 2004;17(2):108-11.

  18. De Madureira PR, De Capitani EM, Vieira RJ. Lead poisoning after gunshot wound. Sao Paulo Med J. 2000;118(3):78-80.

  19. Coon T, Miller M, Shirazi F, Sullivan J. Lead toxicity in a 14-year-old female with retained bullet fragments. Pediatrics. 2006;117(1):227-30.

  20. Linden MA, Manton WI, Stewart RM, Thal ER, Feit H. Lead poisoning from retained bullets. Pathogenesis, diagnosis, and management. Ann Surg. 1982;195(3):305-13.

  21. Qi H. Lung cancer caused by an intrapulmonary bullet and its trajectory--with report of 2 cases. Zhonghua Yi Xue Za Zhi. 1983;63(3):165-6.

  22. Hanzawa S, Wada G. Pulmonary squamous cell carcinoma developing around old bullet wound. Nippon Kyobu Geka Gakkai Zasshi. 1983;31(8):1325-9.

  23. Philip J. Squamous cell carcinoma arising at the site of an underlying bullet. J R Coll Surg Edinb. 1982;27(6):365-6.

  24. Schmitt HP. Trauma and tumor: malignant glioma in the area of a traumatic lesion of the brain with metal scales. Fortschr Neurol Psychiatr. 1983;51(6):227-31.

  25. Witzmann A, Jellinger K, Weiss R. Glioblastoma multiforme developing after a gunshot injury of the brain. Neurochirurgia (Stuttg). 1981;24(6):202-6.

  26. Brogdon BG, Cottrell WC, Nimityongskul P, Takhtani D. A bullet-sired bone cyst. Skeletal Radiol. 2006;35(12):959-63.

  27. Taxin RN, Feldman R. The tumbling bullet sign in a post-traumatic bone cyst. Am J Roentgenol Radium Ther Nucl Med. 1975;123(1):140-3.

  28. Worland RL. Bone cyst following gunshot wound: case report. J Trauma. 1975;15(7):613-5.

  29. Vilits P, Hubmer G. Ureteral obstruction caused by a grenade splinter. Z Urol Nephrol. 1987;80(6):365-8.

  30. Dadsetan MR, Jinkins JR. Peripheral vascular gunshot bullet embolus migration to the cerebral circulation. Report and literature review. Neuroradiology. 1990;32(6):516-9.

  31. Rapp LG, Arce CA, McKenzie R, Darmody WR, Guyot DR, Michael DB. Incidence of intracranial bullet fragment migration. Neurol Res. 1999;21(5):475-80.

  32. Cağavi F, Kalayci M, Seçkiner I, Cağavi Z, Gül S, Atasoy HT, Demircan N, Açikgöz B. Migration of a bullet in the spinal canal. J Clin Neurosci. 2007;14(1):74-6.

  33. Windler EC, SMith RB, Bryan WJ, Woods GW. Lead intoxication and traumatic arthritis of the hip secondary to retained bullet fragments. A case report. J Bone Joint Surg Am. 1978;60(2):254-5.

  34. Smugar SS, Schweitzer ME, Hume E. MRI in patients with intraspinal bullets. J Magn Reson Imaging. 1999;9(1):151-3.

  35. Hess U, Harms J, Schneider A, Schleef M, Ganter C, Hannig C. Assessment of gunshot bullet injuries with the use of magnetic resonance imaging. J Trauma. 2000;49(4):704-9.

  36. Smith CM, Timperley WR. Multiple intraspinal and intracranial epidermoids and lipomata following gunshot injury. Neuropathol Appl Neurobiol. 1984;10(3):235-9.

  37. Hayman J, Huygens H. Angiosarcoma developing around a foreign body. J Clin Pathol. 1983;36(5):515-8.

  38. Himmer O, Lootvoet L, Deprez P, Monfort L, Ghosez JP. Angiosarcoma after total knee prosthesis. Apropos of a case. Rev Chir Orthop Reparatrice Appar Mot. 1991;77(2):125-9.

  39. Albert A, Lootvoet L, Lejeune E, Beugnies A, Himmer O. Angiosarcoma around a knee arthroplasty. Report of a case and literature review. Acta Orthop Belg. 2009;75(4):549-53.

  40. Gebhart M, Fourmarier M, Heymans O, Alexiou J, Yengue P, De Saint-Aubain N. Development of a desmoid tumor at the site of a total hip replacement. Acta Orthop Belg. 1999;65(2):230-4.

  41. Prasad PS, Latham JB, Tucker JK, Ball RY. Disseminated osteosarcoma arising in the pelvis after total hip arthroplasty. J Arthroplasty. 2002;17(3):373-8.

  42. Drexler M, Dolkart O, Amar E, Pritsch T, Dekel S. Late recurrent hemarthrosis following knee arthroplasty associated with epithelioid angiosarcoma of bone. Knee. 2010;17(5):365-7.

  43. Syed AA, Agarwal M, Fenelon G, Toner M. Osseous malignant non-Hodgkin’s B-cell lymphoma associated with total hip replacement. Leuk Lymphoma. 2002;43(11):2213-6.

  44. Weber PC. Epithelioid sarcoma in association with total knee replacement. A case report. J Bone Joint Surg Br. 1986;68(5):824-6.

  45. Bagó-Granell J, Aguirre-Canyadell M, Nardi J, Tallada N. Malignant fibrous histiocytoma of bone at the site of a total hip arthroplasty. A case report. J Bone Joint Surg Br. 1984;66(1):38-40.

  46. Cole BJ, Schultz E, Smilari TF, Hajdu SI, Krauss ES. Malignant fibrous histiocytoma at the site of a total hip replacement: review of the literature and case report. Skeletal Radiol. 1997;26(9):559-63.

  47. Bell RS, Hopyan S, Davis AM, Kandel R, Gross AE. Sarcoma of bone-cement membrane: a case report and review of the literature. Can J Surg. 1997;40(1):51-5.

  48. Schuh A, Zeiler G, Holzwarth U, Aigner T. Malignant fibrous histiocytoma at the site of a total hip arthroplasty. Clin Orthop Relat Res. 2004;(425):218-22.

  49. Nelson JP, Phillips PH. Malignant fibrous histiocytoma associated with total hip replacement. A case report. Orthop Rev. 1990;19(12):1078-80.

  50. Vives P, Sevestre H, Grodet H, Marie F. Malignant fibrous histiocytoma of the femur after total hip prosthesis. Apropos of a case. Rev Chir Orthop Reparatrice Appar Mot. 1987;73(5):407-9.

  51. Swann M. Malignant soft-tissue tumour at the site of a total hip replacement. J Bone Joint Surg Br. 1984;66(5):629-31.

  52. Hughes AW, Sherlock DA, Hamblen DL, Reid R. Sarcoma at the site of a single hip screw. A case report. J Bone Joint Surg Br. 1987;69(3):470-2.

  53. Langkamer VG, Case CP, Collins C, Watt I, Dixon J, Kemp AJ, Atkins RM. Tumors around implants. J Arthroplasty. 1997;12(7):812-8.

  54. Keel SB, Jaffe KA, Petur Nielsen G, Rosenberg AE. Orthopaedic implant-related sarcoma: a study of twelve cases. Mod Pathol. 2001;14(10):969-77.

  55. Visuri T, Pulkkinen P, Paavolainen P. Malignant tumors at the site of total hip prosthesis. Analytic review of 46 cases. J Arthroplasty. 2006;21(3):311-23.