FOR DEBATE

Should airguns be banned?

P. HOLLAND, D. F. O’BRIEN & P. L. MAY

Department of Neurosurgery, Royal Liverpool Children’s Hospital NHS Trust, Alder Hey, Liverpool, UK

AbstractIn this article, we express concerns regarding the availability of airguns, the injuries that they cause and their abuse as weaponsof assault. We wish to stimulate debate on this topic and report a 5-year retrospective analysis of all airgun injuries to the headand neck, presenting to Alder Hey Children’s Hospital, Liverpool, from June 1998 to June 2003. We identified 16 patientswho suffered such injuries with ages ranging from 5 to 15 years. The majority of cases were violent assaults, which is not inaccordance with previous published reports. All of these occurred in public places outside the home. Most incidents occurredthrough the spring and summer period. Six patients required overnight stay in hospital. Nine patients required operativeprocedures to remove the airgun pellets. Two patients had serious eye injuries resulting in loss of vision. Two patients hadpenetrating neck injuries requiring exploration of the wound. The remaining group had either skin-penetrating injuries withlodgement of fragments in subcutaneous tissues or non-skin penetrating injuries. This study highlights serious injuries arisingfrom the abuse of airguns as weapons of assault. Airguns are readily available to people without license. Recent legislation hasincreased the minimum age at which airguns can be carried in a public place, but we believe that stricter legislation is requiredto produce a reduction in the number of airgun-related injuries.

Key words: Head and neck, legislation, paediatric airgun injuries.

Introduction

Airgun injuries can be life threatening. Recent

technological advances have made airguns more

powerful. Despite this, air weapons are widely

viewed as ‘toys’ and their regulation is minimal.1,2

It has been our impression that airgun injuries to the

head and neck are becoming more prevalent in

recent times. This view has been supported by a

London colleague and is set against a background of

a 25% increase in paediatric mortality from all

firearms in the US from 1986 to 1992.3,4

Head and neck injuries have been reported to

represent about one-third of airgun injuries.5 There

are many reports of these injuries penetrating the

adult skull through the eye, temple and forehead.6,7

Children’s skulls are thinner and less resistant to

forces than adults and are even more susceptible to

penetration which, when coupled with the knowl-

edge that most airgun injuries occur to children,

illustrates the potential of significant paediatric

injury.8 Indeed, there is one mortality every year in

the UK from an airgun injury.9

Most studies report that airgun injury incidents are

accidents without malicious intent.10 – 12 Our own

impression is that most airgun incidents are of a

criminal nature and awareness in general needs to be

raised regarding the potency of these weapons. Given

these concerns, we set out to perform a retrospective

analysis of all paediatric patients with airgun injuries

to the head and neck presenting to the Accident and

Emergency Department of Alder Hey Children’s

Hospital between 1998 and 2003. We were inter-

ested in determining the clinical effect of each injury,

the nature of the shooting, be it accident or assault,

the place of the incident and the 6-month outcome

analysis.

Methods

Case records were reviewed to identify all children

presenting to the Accident and Emergency Depart-

ment of Alder Hey Children’s Hospital with airgun

wounds to the head and neck from 1 June 1998 until

1 June 2003. From these records, the following data

were extracted: age and sex of patient, place of

incident, whether it was an accident or an assault, the

type of injury sustained, the need for operative

intervention or not, length of hospital stay and

clinical details relative to follow-up at 6 months after

injury.

Received for publication 8 October 2003. Accepted 26 January 2004.

Correspondence: P. May, Department of Neurosurgery, Royal Liverpool Children’s Hospital NHS Trust, Alder Hey, Eaton Road, Liverpool L12 2AP, UK.

E-mail: paul.may@rlch-tr.nwest.nhs.uk

British Journal of Neurosurgery, April 2004; 18(2): 124 – 129

ISSN 0268-8697 print/ISSN 1360-046X online/04/020124–06 # The Neurosurgical Foundation

DOI: 10.1080/02688690410001680966

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Results

Socio-demographic features

Sixteen patients with airgun injuries to the head and

neck presented during this 5-year period. Ages

ranged from 5 to 15 years old (mean 12.3; Table

I). With the exception of one, all injuries occurred

between 1 April and 31 August. There were 13 male

and three female patients. Five incidents were

accidental, nine were assaults by an unknown

assailant and the cause was unclear in two cases

owing to an inconsistent history. Nine of the 16 cases

presented to hospital later than 18:00 h.

Injuries

Four patients had eye injuries, four had neck wounds

and eight patients had head injuries (Table I). No

patient had both a head and neck injury. All patients

had only one head and neck pellet injury, although

one also had a pellet injury to his shoulder (patient

13). There were no fatalities.

Ten pellets penetrated the skin (Figs 1 and 2). Of

these, eight were removed by a surgical procedure

and two were managed conservatively (patient 2 and

patient 8). However, patient 8 had the pellet removed

at a later date. Three patients had penetrating neck

injuries, of which two had pellet removal and one had

conservative management (Fig. 3).

Two patients had bone penetrating injuries (Table

I, patient 8 and patient 15). In one case, the pellet

penetrated the left orbit and lodged in the right

cavernous sinus (Fig. 4). In the other, it penetrated

the left maxilla and lodged in the base of the left

maxillary sinus.

Of the four patients with eye injuries two had

injuries that penetrated the globe. One injury

FIG. 1. Lateral skull radiograph showing two airgun pellet fragments lodged in the scalp of a child.

TABLE I. Summary of findings

Patient no. Age (years) Sex Impact point Pellet lodged 6-Month outcome

1 14 M Right eye Orbit No vision in right eye

2 15 F Left neck, behind the angle of the mandible Yes N

3 5 M Central forehead No N

4 13 F Right cheek Subcutaneous tissue N

5 13 M Left side of neck, C4 level Adjacent to left internal jugular vein N

6 14 M Right supraorbital region No N

7 11 M Right parietal region Yes N

8 13 M Left maxilla Left maxilla N

9 15 M Left posterior triangle of neck Posterior triangle of neck N

10 15 M Left C4 level No N

11 12 M Left occiput Subcutaneous tissue N

12 7 M Cornea of left eye No N

13 11 F Right infraorbital region No N

14 14 M Right temporal region Subcutaneous tissue N

15 14 M Left eye Right cavernous sinus No vision in left eye

16 11 M Left eye No N

N, normal.

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required enucleation of the globe 20 days after the

injury (patient 1). The other patient with a penetrat-

ing eye injury also lost vision and required explora-

tion of the orbit and removal of the pellet (patient

15). The two remaining patients had non-penetrat-

ing ocular injuries, but had blurred vision and

corneal injury at presentation.

Six patients had non-penetrating injuries. Six of

the 16 patients required an overnight stay in hospital.

Outcome

Six months after injury patients 1 and 15 were

without any vision in the injured eye (Table I).

Patients 8 and 15 had a lodged pellet that was

managed conservatively and are under 6-monthly

review. All other patients had fully recovered by 6

months.

Discussion

Sixteen children were included in our study. The

actual number of airgun injuries may be higher, as

patients with minor injuries may not have presented

to hospital. Airgun injuries that did not present to

hospital can cause considerable psychological and

physical distress, and the actual morbidity may be

under-represented. The cases in this study demon-

strate the morbidity that these injuries cause: two

children lost total vision in the injured eye and nine

patients underwent operations, five of which were

relatively major procedures. We are convinced that

this problem is neither confined to the paediatric

population nor the Liverpool suburban area and that,

as technology develops, injuries from airguns will

become more prevalent.

Airguns can fire pellets at up to 826 feet per second

(with kinetic energy of 16.27 Joules). It has been

reported that a pellet travelling at 290 – 370 feet per

second (2.0 – 3.25 J) has sufficient energy to pene-

trate the skin. Those travelling at approximately

130 – 236 feet per second (0.41 – 1.33 J) have suffi-

cient energy to penetrate the eye.13 – 15 Airguns can

fire at 11 times the energy needed to penetrate the

skin and 40 times the energy needed to penetrate the

eye. In the UK, air rifles and pistols firing greater than

12 foot pounds (16.27 J) and 6 foot pounds (8.14 J),

respectively, are classified as a firearm, and a firearms

licence is needed to own and fire them.2 Airguns

firing with less power than one foot pound (1.36 J)

are not covered at all by the Firearms Act 1968.2

Changes to the law, on the 20 January 2004, have

increased the minimum age at which an airgun can be

carried in a public place by 3 years. This means that

any person aged 17 years or over can carry an airgun

in a public place. Children 14 years and over can still

fire an airgun unsupervised on private land.1 Chil-

dren under 14 can fire airguns when supervised by

FIG. 2. Antero-posterior skull X-ray showing an airgun pellet in the

scalp in the occipital region.

FIG. 3. Lateral neck X-ray showing an airgun pellet adjacent to the

C4 vertebral body.

126 P. Holland et al.

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anyone over 21 years.1 We are sceptical as to whether

these changes to the law will reduce the frequency of

airgun injuries and believe that airguns should be

controlled by the same laws as firearms.

In the USA there is no national legislation cover-

ing airguns but eleven States recognize airguns as

firearms. Despite the lack of national legislation

regulating airguns the individual state legislations, on

the whole, appear to control these weapons more

closely than UK law.

Pellets have been reported to penetrate the nose,

which is the weakest facial bone, the temporal bone

and the frontal bone.6,7,17,18 The orbit is made of

bone that, even in its strongest superior and lateral

walls, is so thin that it is transparent.19 Hence, when

fired into the eye, even low power airguns have

sufficient energy to penetrate right through the

eyeball, penetrate the orbit and enter the brain. This

occurred in patient 15 and has been widely re-

ported.20 – 23 Children’s orbits are particularly vulner-

able to penetration as they are not as strong as adults.

Airguns and pellets can be designed in such a way

to limit their ability to cause injury. The pellets for

the Blue Streak and Silver Streak airguns are

designed in a such a way that they are less

penetrating than the almost universally used tradi-

tional airgun pellets.24 Of some concern is that it is

possible to modify airguns and pellets enabling them

to fire with more energy.25 Modified airguns are

powerful enough to be classified as firearms under

UK law. The other danger is that modified airguns

may not have been through the safety checks that are

performed when airguns are manufactured and may

not be safe to use.25 No study has included a

detailed analysis of the airgun and pellet type

involved in injuries, and it is unclear what propor-

tion of airgun injuries are from modified weapons.

However, adapted pellets have been reported to

cause injury and death.7 Introducing strict regula-

tions regarding the design of airguns and pellets is

needed to make these weapons safer and less easy to

modify.

A

BFIG. 4. (A) CT scan of an airgun injury to the left eye showing destruction of the lens. (B) Further CT images of the same patient showing

artefact from the airgun pellet that is lodged in the right cavernous sinus (middle picture). The CT slice on the extreme right shows the high

density of the airgun pellet tip in the right cavernous sinus.

Should airguns be banned? 127

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The seriousness of an airgun injury is not always

obvious at presentation. In this study, eight patients

presented with a history of walking in a public place

and then feeling a sharp stinging pain. Another

patient, who briefly lost consciousness, was unsure

whether he had been hit by a ball or had run into a

wall. Indeed, there have been reports of central

nervous system penetrating injuries, where the

patient and parents had been unaware that the pellet

had even penetrated the skin.11,26 The diagnosis may

be more difficult because the pellet may not be

palpable. The pellet was too deep to palpate in seven

of our patients. However, the pellet was palpable in all

three patients with a subcutaneously-lodged pellet.

The diagnostic danger is that, because the entrance

wound is often small and the pellet not palpable, deep

penetrating injuries could easily be treated as minor

or missed altogether.6,27 If a superficially lodged

pellet is untreated there is a risk of infection and a

small risk of lead poisoning.21 If the pellet has

penetrated the central nervous system and remains

untreated, serious infection can ensue. It is impor-

tant, especially on summer evenings when most of

our cases presented, to be aware that children with

apparently trivial injuries may have been shot by an

airgun. Missed diagnosis could result in an easily

managed injury becoming catastrophic.

The majority of the injuries in this study were the

result of an assault by an unknown assailant. It has

been reported that unaccompanied children are

usually the assailants and that adults are rarely in

the immediate area of a shooting.1,11,25 It is very

difficult to get any reliable data on the assailants. We

assume that the assailants are predominantly chil-

dren or teenagers. The high number of assaults

causing the injuries in this study are in contrast to

other studies, which show that the majority of

injuries are accidental. It is our personal view that

familiarity with airguns through their almost over-

the-counter availability and the mechanism of their

use may well encourage progression to the use of

illegal firearms (guns, shotguns) with criminal intent.

Conclusions

Airguns are dangerous weapons, yet they are readily

available to children and often considered to be toys

(Fig. 5). Injuries caused by these weapons are often

serious. We believe that children and teenagers

playing with airguns are unaware of the severity of

injury that they can cause and, hence, behave

unsafely. Recent changes to airgun law are minimal,

and we feel that stricter legislation is needed to make

airguns safer and reduce their availability to children

and teenagers.

References

1 United Kingdom Anti-Social Behaviour Act, 2003

2 United Kingdom Firearms Act, 1968.

3 Girdler NM. Facial Airgun Wound (Case Report). J Trauma

1995;38:390 – 391.

4 United States National Centre for Injury Prevention and

Control. Injury Mortality: National Summary of Injury Mortality

Data, 1986 – 1992. Atlanta, Georgia, USNCIPC, 1995.

5 Scribano PV, Nance M, Reilly P, Sing RF, Selbst SM.

Paediatric nonpowder firearm injuries: outcomes in an urban

paediatric setting. Pediatrics 1997;100(4):e5.

6 Shaw MD, Galbraith S. Penetrating Airgun injuries of the

Head. Br J Surg 1977;64:221 – 224.

7 Green GS, Good R. Homicide by use of a pelletgun. Am J

Forensic Med Pathol 1982;3:361 – 365.

8 Abbass Amirjamshid, Kazem Abbassioun, Hadi Roosbeh. Air-

gun pellet injuries to the head and neck. Trauma

1997;47:331 – 338.

9 Warlow TA. Firearms, the law and forensic ballistics. London:

Taylor & Francis, 1999.

10 Bratton SL, Dowd MD, Brogan TV, Hegenbarth MA. Serious

and fatal air gun injuries: more than meets the eye. Pediatrics

1997;100:609 – 612.

11 O’Connell JE, Turner NO, Pahor AL. Air gun pellet in the

sinuses. J Laryngol Otol 1995;109:1097 – 1100.

12 Christoffel KK, Tanz R, Sagerman S, Hahn Y. Childhood

injuries caused by nonpowder firearms. Am J Dis Childh

1984;138:557 – 561.

13 Reddick EJ, Carter PL, Bickerstaff L. Homicide by use of a

pellet gun. Ann Emerg Med 1985;14:1108 – 1111.

14 Delori F, Pomeratzeff O, Cox MS. Perforation of the globe

under high speed impact: its relation to contusion injuries.

Invest Ophthalmol 1969;8:290 – 301.

15 Barnes FC, Helson RA. A death from an airgun. J Forensic Sci

1976;6:1 – 3.

16 Buckes BA. State laws and published ordinances. Washington

DC, United States Department of the Treasury, Bureau of

Alcohol, Tobacco and Firearms, 2001.

17 Hampson D. Facial injury: a review of biomechanical studies

and test procedures for facial injury assessment. J Biomech

1995;28:1 – 7.

18 Monticelli F, Seidl S, Betz P. Air rifle injury with an entrance

through the Nose: a case report and review of the literature. Int

J Legal Med 2002;116(5):292 – 294.

FIG. 5. A typical airgun- a weapon or a toy? Photograph reproduced

with permission from istockphoto.com.

128 P. Holland et al.

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19 Moore KL, Dalley AF. Clinically orientated anatomy. Hagers-

town: Lippincott Williams and Wilkins, 2001.

20 Shuttleworth GN, Galloway PH. Occular air-gun injury: 19

cases. J Roy Soc Med 2001;94(8):396 – 399.

21 Bowden DI, Magauran DM. Ocular injuries caused by airgun

pellets: an analysis of 105 cases. BMJ 1973;1:333 – 337.

22 Sharif KW, McGhee CNJ, Tomlinson RC. Ocular Trauma

caused by airgun pellets: a ten year survey. Eye 1990;4:855 –

860.

23 Kreshon MJ. Eye injuries due to BB guns. Am J Ophthalmol

1964;58:858 – 861.

24 Steindler RA. Airgun pellet penetration. Med Sci Law

1980;20(2):93 – 98

25 Milroy CM, Clark JC, Carter N, Rutty G, Rooney N. Air

weapon fatalities. J Clin Pathol 1998;51:525 – 529.

26 Martinez-Lage JF, Gilabert JMA. Airgun pellet injuries to the

head and neck in children. Pediat Surg Int 2001;17:657 – 660.

27 Schein OD, Enger C, Tielsch JM. The context and con-

sequences of occular injuries from airguns. Am J Ophthalmol

1994;117:501 – 506.

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