"Pellet storm": a case of 'mis-lead-ing' foreign body removal

Abstract

Retained lead foreign bodies from industrial blast injuries pose dual challenges: complexity of immediate surgical extraction and long-term systemic lead toxicity risk (plumbism). Lead pellet injuries can result in blood lead levels (BLL) exceeding safe thresholds (>10 μg/dl adults), with severe toxicity at BLL >80 μg/dl. Surgical decision-making must balance the risks of invasive extraction against the risks of retained metallic lead. A 40-year-old male sustained a workplace blast injury when a lead welding machine exploded. He presented with a 5×6×2 cm wound on the lateral right thigh with active hemorrhage, partially charred subcutaneous tissue, and visible lead pellets. Initial radiographs demonstrated 98 round radio-opaque foreign bodies scattered throughout the right femur, thigh musculature, and one pellet in the left thumb. Primary survey confirmed hemodynamic stability (GCS 15/15, BP 122/80 mmHg, SpO₂ 97%). Femoral and popliteal pulses were intact bilaterally. Following re-suscitation and wound stabilization, exploratory surgery under C-arm fluoroscopic guidance achieved extraction of 78 pellets from vastus lateralis and medialis via medial and lateral thigh incisions. Approximately 20 pellets adjacent to the neurovascular bundle in the posterior com-partment were deliberately left in situ to avoid iatrogenic vascular or nerve injury. Estimated blood loss: 600 mL; intraoperative transfusion administered. Postoperative course complicated by wound infection on day 5, managed with debridement, culture-directed antibiotics, vacuum-assisted closure (VAC) therapy, and split-thickness skin graft. Patient discharged in haemody-namic stable status and, ambulatory with healed wound. Two-month follow-up showed no signs of infection, sinus tract formation, or clinical plumbism (patient subsequently lost to follow-up). This case illustrates the surgical challenge of balancing maximal foreign body extraction against the risk of neurovascular injury in penetrating trauma with multiple retained projectiles. The decision to leave ~20% of pellets in situ near critical structures reflects established trauma principles prioritizing preservation of neurovascular function over complete foreign body re-moval. Long-term plumbism risk remains uncertain; prospective data on lead toxicity from re-tained pellets are limited, though existing case series suggest elevated BLL can persist for months to years. Clinical and serological surveillance (serum lead levels, complete blood count) is recommended but was not completed in this case due to loss of follow-up.