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AJR 2001; 176:1144
© American Roentgen Ray Society

Trauma Cases from Harborview Medical Center

Lead Arthropathy and Systemic Lead Poisoning from an Intraarticular Bullet

Joseph DeMartini1, Anthony Wilson1, Jerry S. Powell2 and Clermont S. Powell3

1 Department of Radiology, Harborview Medical Center, University of Washington School of Medicine, 325 Ninth Ave., Box 359728, Seattle, WA 98104-2499.
2 Division of Hematology and Oncology, University of California, Davis Cancer Center, 4501 X St., Sacramento, CA 95817.
3 Department of Pathology, Harborview Medical Center, University of Washington School of Medicine, Seattle, WA 98104.

Received October 31, 2000; accepted after revision October 31, 2000.

 
This is another in the continuing series on radiology in trauma cases from the Harborview Medical Center. Editors: Fred A. Mann and Eric J. Stern.

Address correspondence to F. A. Mann.


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A 55-year-old man presented to the department of neurology with muscle wasting. Initially hyperreflexic, he later became markedly hyporeflexic and developed signs of peripheral neuropathy. Over the course of approximately 3 months, various diagnoses were entertained. An extensive workup revealed that he was profoundly anemic, despite normal iron studies. On the basis of results of a bone marrow aspiration, lead poisoning was considered. His serum lead level was 198 µg/dL (normal range, 0-30 µg/dL), indicating chronic lead poisoning. The only identifiable source for this elevated serum lead level was a retained bullet in the patient's left hip, from a gunshot wound 15 years earlier. Hip radiographs obtained at the time of injury (Fig. 1A) showed a deformed bullet lodged in the hip joint. Later studies revealed fragmentation of the bullet, with distribution of fragments throughout the hip joint, and associated severe osteoarthritis (Fig. 1B). The patient was started on chelation therapy, and left-hip synovectomy and hemiarthroplasty were performed. The patient's serum lead level dropped to normal range within 2 weeks.



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  		Fig. 1A. —55-year-old man with lead arthropathy from an intraarticular bullet. Anteroposterior radiograph of hip obtained at time of initial injury shows deformed bullet lodged in superolateral aspect of joint.

 


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  		Fig. 1B. —55-year-old man with lead arthropathy from an intraarticular bullet. Fifteen years after initial injury, bullet has fragmented. Fragments are distributed throughout hip joint, resulting in "lead arthrogram." Joint cartilage has been destroyed and patient has severe lead arthropathy.

 

Patients with gunshot wounds often have retained bullet fragments. In most cases, lead fragments in soft tissues become encapsulated by fibrous tissue, and are effectively inert. This is not the case when bullet fragments are in contact with synovial fluid. Intra-articular lead fragments are a well-recognized cause of lead synovitis and arthritis, as well as systemic plumbism. Lead poisoning from intraarticular bullets has been recognized since 1867 [1]. Mechanical forces within the joint pulverize the bullet and distribute the lead fragments. These lead fragments interact with the acidic synovial fluid, producing foreignbody reactions, mechanical articular cartilage damage, proliferative synovitis, and destructive arthritis. The inflamed synovial membrane favors absorption of lead into the systemic circulation [2].

The fragmentation and migration of bullet fragments throughout the joint are well depicted on serial radiographs (Fig. 1A,1B). The articular cartilage thins and may become visible because of the deposition of lead particles, with an appearance resembling chondrocalcinosis. The inner surface of the synovium may become similarly opacified by fine lead particles [3,4,5]. Ultimately, the entire joint capsule and cartilage may become outlined, resulting in a "lead arthrogram" or "plumbogram" (Fig. 1B).

Lead arthropathy and systemic plumbism from retained bullet fragments usually present years or decades after the patient was shot. Because the symptoms may be vague and intermittent, and the treating physician may be unaware of the gunshot injury, diagnosis may be delayed.

The radiographic identification of intraarticular bullet fragments should prompt an urgent orthopedic consultation. The timely removal of lead particles and débridement of bone and cartilage fragments will prevent both lead arthropathy and toxicity [4]. If lead arthropathy is identified, synovectomy and joint replacement are often necessary. All patients with lead arthropathy should be evaluated for systemic lead toxicity [5].


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  1. Dillman RO, Crumb CK, Lidsky MJ. Lead poisoning from a gunshot wound: report of a case and review of the literature. Am J Med 1979;66:509 -514[Medline]
  2. Slavin RE, Swedo J, Cartwright J Jr, Viegas S, Custer EM. Lead arthritis and lead poisoning following bullet wounds: a clinicopathologic, ultrastructural, and microanalytic study of two cases. Hum Pathol 1988;19:223 -235[Medline]
  3. Sclafani SJA, Vuletin JC, Twersky J. Lead arthropathy: arthritis caused by retained intraarticular bullets. Radiology 1985;156:299 -302[Abstract/Free Full Text]
  4. Hollerman JJ, Fackler ML, Coldwell DM, Ben-Menachem Y. Gunshot wounds: 2. Radiology. AJR 1990;155:691 -702[Abstract/Free Full Text]
  5. Farber JM, Rafii M, Schwartz D. Lead arthropathy and elevated serum levels of lead after a gunshot wound of the shoulder. AJR 1994;162:385 -386[Free Full Text]

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