School of Podiatric Medicine - Student Research

Document Type

Poster

Publication Date

Spring 2026

Abstract

Level of Evidence: III (Case Study)

Statement of Purpose: Gunshot wounds to the foot pose a unique surgical dilemma—whether to pursue aggressive foreign body removal or to preserve soft tissue integrity. This case highlights the management of a birdshot injury to the rearfoot where selective non-removal of pellets near the neurovascular bundle led to complete healing and full functional recovery. The purpose is to emphasize tissue preservation over aggressive exploration in complex ballistic foot injuries.

Case Study: A 26-year-old female sustained a birdshot gunshot wound to the right rearfoot. Multiple small entry wounds were noted on the posterior and plantar aspects of the foot, with localized edema and tenderness. Distal pulses, motor strength, and sensation were intact, confirming no neurovascular compromise.

Radiographs revealed numerous metallic pellets embedded in the soft tissues of the rearfoot, without osseous or intra-articular involvement.

On February 14, the patient underwent irrigation, debridement, and removal of superficial fragments. Several deeper pellets were left in situ due to proximity to the posterior tibial neurovascular bundle to prevent iatrogenic injury. An acellular dermal graft was applied, followed by a wound VAC secured with gauze and an ACE wrap for moderate compression.

At the first postoperative visit on February 27, the wound demonstrated healthy granulation tissue with no infection. During the third postoperative visit, after seeking a second opinion on closure options, the patient elected suprafascial flap coverage rather than continued VAC therapy.

On March 15, a transpositional flap was performed with a reinforcing graft, and vancomycin powder was applied to support wound healing. By March 21, the wound demonstrated advanced granulation tissue, stable and well vascularized with sutures in place; follow-up was scheduled in two weeks for suture removal.

At subsequent visits (April 5, April 19, and May 2), the wound showed complete epithelialization and closure by secondary intention, with no drainage, infection, or foreign body reaction. The patient progressed to full weight-bearing in regular footwear, reporting no residual pain or functional limitation. Follow-up was discontinued after May 2 due to loss of insurance coverage; however, the patient remained well and reported no concerns.

Results: • Complete wound healing by secondary intention within 10 weeks. • No postoperative infection or neurovascular complications. • Retained pellets remained stable without migration or symptomatic reaction. • Full restoration of foot function and ambulation.

Analysis and Discussion: Gunshot wounds to the foot are uncommon but clinically significant due to the foot’s limited soft-tissue envelope and complex anatomy. Gunshot wounds to the foot represent approximately 5% of all firearm-related extremity injuries (HMP Global Learning Network). Although data on birdshot injuries are limited, the ballistics—multiple small pellets with variable penetration—are well described in shotgun literature.

Current evidence supports selective removal of ballistic fragments, with extraction reserved for intra-articular, infected, or neurovascularly impinging pellets according to Reilly et al. Aggressive pursuit of deeply embedded fragments can increase morbidity and delay healing.

This case demonstrates that conservative management—with limited debridement, staged grafting, and flap coverage—can achieve excellent functional and cosmetic outcomes when fragment removal poses a risk to vital structures. In select ballistic injuries of the foot, preserving viable tissue may be the best intervention.

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