Multiple re-entry gunshot wounds possibly inflicted by a single shot: Case report

These investigations reveal the shooting direction, shooting distance, weapon type, victim position at the time of shooting, direction of the bullet hitting the body and the relevant organs. However, it is diffi cult to determine the shooting distance and to distinguish the entry-exit wounds in patients who have unknown injuries, no initial examination fi ndings and received medical treatment [2,3].

Fireguns continue to attract people's attention today as they have in the past. People obtain fi reguns for individual purposes such as hunting, protection or defense. Again, fi rearms are manufactured for institutional purposes and used for deterrence, defense, and even for attacking in order to eliminate danger and threat [1].
Firearm wounds are frequently encountered in forensic practice [1]. The person can shoot himself or be shot by someone else. Firearm wounds have the same appearance in either case. Therefore, autopsy is recommended for fi rearmrelated deaths [2]. Firearm wounds are examined by forensic medical experts for the identifi cation of ballistic trajectory as well as entry and exit wounds. In case of fi regun-related injuries, it is important to make investigations to determine the shooting distance, to determine the entry and exit wounds, to analyze the residues on the clothes and the body, and to preserve the clothes [1,2].
These investigations reveal the shooting direction, shooting distance, weapon type, victim position at the time of shooting, direction of the bullet hitting the body and the relevant organs.
However, it is diffi cult to determine the shooting distance and to distinguish the entry-exit wounds in patients who have unknown injuries, no initial examination fi ndings and received medical treatment [2,3].
Another diffi culty encountered in distinguishing entry and exit wounds is when there are re-entry wounds. It is quite common for different parts of the body to be injured by one projectile because a single fi rearm projectile can cause several injuries. Re-entry wounds occur when a projectile pierces one part of the body such as an arm and then enters another part of the body such as the rib cage, for example. The most common situation is when the bullet travels across the arm or leg and then re-enters the abdomen or chest. Initially pierced body parts such as arms or legs, can be considered as an intermediate target. Placing the limb in the proper position immediately clarifi es the situation and can signifi cantly aid direction estimation [4,5].
Determining the number of shots in fi rearm injuries is important in cases in order to determine the origin by judicial authorities where there is more than one suspect. Consequently, re-entry wounds should be taken into consideration when interpreting the number of shots. In cases with re-entry-exit wounds, trajectory can be detected in the examination where the limbs such as arms and legs are placed in the appropriate position at autopsy.
In this case, the same bullet entered from the posterior left shoulder and exited from the left side of the neck and then reentered 2 cm above the area where it exited on the neck, causing injury to re-exit from the back of the right ear, resulting in reentry-exit wounds in this manner. It has been determined that there are differences between re-entry-exit wounds, which are widely seen in the literature, in terms of factors such as injury site and trajectory, therefore, our report aimed to discuss the methods to be followed to determine the number of shots, trajectory and entry-exit wounds in autopsies performed in re-entry-exit injuries, and to emphasize that re-entry and exit wounds should be taken into account in single-shot cases where it is diffi cult to distinguish entry-exit wounds.

Internal examination
When the skull was opened and the dura mater was removed, we observed a subdural hemorrhage of 6x2 cm in the right frontal lobe and 9x2 cm in the side facing the interhemispheric area in the parietal lobe, and a diffuse subarachnoid hemorrhage in both parietooccipital lobes. The brain, cerebellum and organs that make up the brainstem were

Discussion and conclusion
In fi rearm injuries, it is of great importance to determine It may be diffi cult to determine the number of shots and the shooting distance, and to distinguish between entry-exit wounds in cases with multiple entry-exit wounds,it is not known how the injury occurred, there are no fi rst examination fi ndings, and especially those who have received medical treatment [3].
In a case presented in the literature on this subject, the body of a 73-year-old male was found in a truck where external examination found 18 gunshot wounds on the upper arms, neck and head, but 6 shots were fi red according to the police report, revealing a case of re-entry and exit wounds [6]. In another case, it was determined that the victim had 2 entry and one exit wounds due to a fi rearm injury, where it was later found that the victim was leaning against the wall when shot, and the bullet came out of the victim's back and bounced off the wall and entered the body again [5].
In our case, there was diffi culty in distinguishing and tracing fi rearm entry-exit wounds due to factors such as the presence of surgical wounds on the victim's body as a result of medical intervention in the hospital where he was admitted after being shot, loss of the characteristics of some described fi rearm wounds after surgical intervention, and inadequate information in forensic analysis. In addition, the forensic investigation fi le did not contain information about the ballistic examination. For this reason, a defi nite assessment could not be made regarding the ammunition and weapon type used.
Gunshot wounds typically appear as central tissue defects with a thin circular blackish abrasion rim resulting from the accumulation of lubricant, dirt and rust in the barrel on the tissue during penetration by the projectile, an abrasion ring around the abrasion rim and ecchymotic area at the outermost part. However, not all of these are always seen. Most entry wounds appear as circular punctures with an abrasion margin or abrasion ring. Abrasion margin is produced due to stretching as the bullet enters the body by ultimately tearing the adjacent skin surface and is the most reliable feature in identifying entry wounds. Abrasion margin can provide useful preliminary information regarding the trajectory of a projectile within the body. Abrasion margin is symmetrical when the bullet enters the body perpendicularly. When the bullet enters the body at a certain angle, the margin on the side where the bullet fi rst contacts the skin will increase [4,7].
The wound morphology that occurs in fi rearm exit wounds is variable, they are generally larger and irregular than the entry hole. Exit wounds are generally in the form of an irregularly shaped lesion in which the skin and tissues are torn outward. In contrast to the entry, the skin at the exit protrudes outward and generally appears as slit-like or irregular holes with no wear margins [4,7,8].
Injury at two parts of the body with a single shot is quite common. Re-entry wounds occur when a bullet pierces one part of the body, such as an arm, and then enters another area, such as the chest. Initially pierced body part can be considered as an intermediate target. Re-entry wounds commonly present as a large and irregular defect with ragged edges and a wide abrasion ring but no bullet wipe-off [4,5].
In our case, gunshot injuries defi ned in the waist, abdomen and right knee medial were tracked as initially thought.
Considering the position of the body during the shooting it would have been possible to consider the possibility that the wound number 7 is a re-entry wound from number 6, but the data that is given by the crime scene investigation offi cers did not reveal the position of the body or present any video recordings of the shooting. Therefore during the autopsy and the preparation of the autopsy report, we didn't consider the possibility that the wound number 7 would be a re-entry wound from the wound number 6.  (Figures 2,3).
In conclusion, we are of the opinion that the evaluation should be made in accordance with the forensic analysis and medical treatment documents in cases where it is diffi cult to distinguish between fi rearm entry-exit wounds, it is not known how the injury occurred and the initial examination fi ndings are unavailable.We believe that it should also be taken into account that multiple fi rearm entry and exit wounds may occur with a single shot.