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Currently, crossbows are involved in some deaths, including suicides. These are rare events for which an accurate study of the body discovery site and reconstruction of the triggering mechanism of the crossbow represent crucial medicolegal elements. In this report, a unique case of suicide by crossbow is presented, in which the male victim constructed an elaborate scenario. He arranged two tripod stands to hold the crossbow at the height of his head, and a third to support a hollow tube positioned in front of the muzzle of the crossbow to direct the bolt. After positioning the center of the forehead in front of the hollow tube, the trigger was activated from a distance using a hooked metal rod. The methods used prompted a literature review on suicide by crossbow, which revealed only 14 reports from 1993 to 2023. The head and chest were the main target areas, and in almost all cases, the victims directly pulled the trigger with their finger. Only one case of indirect triggering was found, with the chest as the target. Therefore, in this scenario, the case presented stands as a unique report, due to the elaborate system devised to carry out the suicide and accurately strike the predetermined target.

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INTRODUCTION: Crossbow injuries are rare but carry significant morbidity and mortality, and there is limited evidence in the medical literature to guide care. This paper reviews the case reports and case series of crossbow injuries and looks for trends regarding morbidity and mortality based on the type of arrow, anatomic location of injury, and intent of injury. METHODS: Multiple databases were searched for cases of crossbow injuries and data were abstracted into a spreadsheet. Statistics were done in SPSS. RESULTS: 358 manuscripts were returned in the search. After deduplication and removal of nonclinical articles, 101 manuscripts remained. Seventy-one articles describing 90 incidents met the inclusion criteria. The mean age was 36.5 years. There were 10 female and 79 male victims. Fatality was 36% for injuries by field tip arrows and 71% for broadhead arrows, p = .024. Assaults were fatal in 84% of cases, suicides in 29%, and accidental injuries in 17%, p < .001. Mortality was similar for wounds to the head and neck (41%), chest (42%), abdomen (33%), extremities (50%), and multiple regions, p = .618. CONCLUSIONS: Crossbows are potentially lethal weapons sold with fewer restrictions than firearms. Injuries caused by broadhead arrows are more likely to be fatal than injuries from field tip arrows. The anatomic location of injury does not correlate with fatality. More than half of crossbow injuries are due to attempted suicide, with a high case-fatality rate.

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Background: Low-energy penetrating head injuries caused by arrows are relatively uncommon. The objective of this report is to describe a case presentation and management of self-inflicted intracranial injury using a crossbow and to provide a relevant literature review. Case Report: A 31-year-old man with a previous psychiatric history sustained a self-inflicted injury using a crossbow that he bought from a department store. The patient arrived neurologically intact at the hospital, fully awake and oriented. He was not able to verbalize due to immobilization of the jaw as well as fixation of his tongue to his hard palate secondary to the position of the arrow. The trajectory of the object showed an entry point at the floor of the oral cavity and an exit through the calvarium just off the midline. The oral and nasal cavity, along with the palate and, the skull base of the anterior cranial fossa, and the left frontal lobe, were all breached. No vascular injury was identified clinically or in imaging. The arrow was surgically removed in the operating room after establishing an elective surgical airway. The floor of the mouth, tongue, and palate was repaired next. A planned delayed cerebrospinal fluid leak repair was performed. The patient made a substantial recovery and was discharged home in good functional status. A systematic literature search was done using Medline for cases with intracranial injuries related to crossbows to review and appraise the available literature. Conclusion: A thorough assessment in a multidisciplinary trauma center and the availability of a subspecialty care team, including neurosurgery and otolaryngology, are paramount in such cases. The vascular imaging should be done before and after any planned surgical intervention. Emergent and elective surgical airway management should be considered and made available throughout the stabilization and care of the acute injury. Surgical management should be planned to remove the object with adequate exposure to facilitate visualization, removal, and the possible need for further intervention, including anticipating aerodigestive and vascular injuries on removal. Finally, access to weapons and the relation to psychiatric illness should not be overlooked, as many reported cases are self-harming in nature.

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Injuries and deaths from crossbows are uncommon, especially when self-inflicted. We present here the case of a 45 years old patient with history of mental illness, who attempted suicide with a crossbow. The bolt penetrated the chin, crossed the oral floor, the oral cavity, the bony palate, the left nasal cavity and exited at the level of the nasal bones. The main concern was the management of the airways, before proceeding to the removal of the bolt. A nasotracheal intubation through the right nasal cavity while the patient was conscious was performed, but the instruments needed for an emergency tracheotomy were in the operating room in case of failure. The intubation was successful, he underwent general anesthesia, and the bolt was removed from the face.

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ETHNOPHARMACOLOGY RELEVANCE: Crossbow-medicine needle therapy (microneedle roller combined with crossbow-medicine) is one of the external treatment methods of Miao Medicine in China. It is a way of combining acupuncture with Chinese herbal medicine, which is widely used in clinical treatment of pain. AIM OF THE STUDY: To observe the transdermal absorption promoting effect of microneedle roller via transdermal administration, and to discuss the transdermal absorption characteristics and the safety of crossbow-medicine needle therapy. METHODS: Based on the determination of the content of the main components of crossbow-medicine prescription in our previous research, the present experiment was conducted in-vitro and in-vivo experiments and the skin of rats was used as the penetration barrier. For in-vitro experiment, the modified Franz diffusion cell method was used to determine the transdermal absorption rate and 24h cumulative transdermal absorption amount of the active ingredients of crossbow-medicine liquid. For in-vivo experiment, tissue homogenization was applied to compare the skin retention amount and plasma concentration of crossbow-medicine liquid absorbed at different time points via the aforementioned two modes of administration. Furthermore, the effect of crossbow-medicine needle on the morphological structure of rat skin stratum corneum was detected by hematoxylin-eosin (HE) staining. The safety of crossbow-medicine needle therapy was evaluated according to the scoring criteria of the skin irritation test. RESULTS: 1. In-vitro experiment: In the microneedle-roller group and crossbow-medicine liquid application group, the effect of transdermal delivery was identified in all the four ingredients of anabasine, chlorogenic acid, mesaconitine and hypaconitine. The 24h cumulative transdermal absorption amount and transdermal absorption rate of each ingredient in microneedle-roller group were significantly higher than those in crossbow-medicine liquid application group (all P < 0.05). 2. In-vivo experiment: Both microneedle-roller and crossbow-medicine liquid application could promote the transdermal absorption of the active ingredients of the drug in the skin and retain in the skin structure. After 8h of administration, the total retention amount of anabasine, chlorogenic acid, mesaconitine and hypaconitine in the skin of rats in the former group was significantly higher than that in the latter group (all P < 0.05). 3. HE staining: In the blank group, the stratum corneum showed an evenly zonal distribution on the active epidermis, and had a close connection with the epidermis, without exfoliation or cell dissociation of the stratum corneum. The crossbow-medicine liquid group had a relatively complete stratum corneum, with a small proportion of exfoliation or cell dissociation, loose arrangement and loose connection with the epidermis. In the microneedle-roller group, the skin had pore channels, and the stratum corneum was loose and exfoliated, which showed zonal distribution in a free state and a high degree of separation. The crossbow-medicine needle group had loose the stratum corneum, broken and exfoliated, which was separated from the active epidermis and showed zonal distribution in a free state. 4. SAFETY: No obvious erythema, edema and skin protuberance were observed in the skin of rats treated with microneedle roller, crossbow-medicine liquid and crossbow-medicine needle. Additionally, the skin irritative response score was 0. CONCLUSION: Microneedle roller can promote the transdermal absorption of crossbow-medicine liquid, and crossbow-medicine needle therapy has good safety.

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BACKGROUND: Modern crossbow is a popular weapon used throughout the United States for outdoor recreation. Crossbow mechanics place the hand and digits at significant risk of injury while shooting or handling these weapons; however, injury patterns have been poorly documented. In this study, the authors use a national database to assess patterns of crossbow-related injuries of the hand and digits. METHODS: A retrospective review of the National Electronic Injury Surveillance System database was conducted to identify crossbow-related hand and digit injuries over the past 10 years. Demographic data, injury timing, anatomical injury location, specific injury diagnosis, and disposition data were collected. RESULTS: A total of 15 460 crossbow-related hand injuries were identified between 2011 and 2021. A strong temporal relationship was identified, with 89% of injuries occurring between the months of August and December. Male patients sustained most injuries (>85%). Body areas injured were the digits (93.2%) and the hand (5.7%). The most common injuries were laceration (n = 7520, 48.6%), fracture (n = 4442, 28.7%), amputation (n = 1341, 8.7%), and contusion/abrasion (n = 957, 6.2%). More than 50% of cases involved injury to the thumb, with approximately 750 thumb amputations recorded during the time period examined. CONCLUSIONS: This study is the first to document the patterns of hand and digit injuries associated with crossbow use on a national scale. These findings have important implications for public health awareness campaigns targeting hunters and support the designation of crossbow "safety wings" as a mandatory feature of crossbow design.

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OBJECTIVE: To observe the clinical efficacy of Miao medicinal crossbow acupuncture therapy as adjuvant treatment for lung cancer pain based on oxycodone hydrochloride extended-release tablet. METHODS: A total of 60 patients with lung cancer pain were randomized into an observation group (30 cases, 1 case dropped off) and a control group (30 cases). In the control group, oxycodone hydrochloride extended-release tablet was given orally, 10 mg a time, once every 12 hours. On the basis of the treatment in the control group, Miao medicinal crossbow acupuncture therapy was applied once every other day in the observation group. The treatment of 14 days was required in the two groups. Before and after treatment, the numerical rating scale (NRS) score, number of break-out pain and Karnofsky performance status (KPS) score were observed in the two groups. The equivalent oxycodone consumption and rate of adverse reactions were recorded, the analgesic effect was evaluated in the two groups. RESULTS: Compared before treatment, the NRS scores and number of break-out pain were decreased while the KPS scores were increased after treatment in the two groups (P<0.01). After treatment, the NRS score and number of break-out pain in the observation group were lower than the control group (P<0.01), the KPS score in the observation group was higher than the control group (P<0.05). The equivalent oxycodone consumption of whole course and the rate of adverse reactions i.e. constipation, drowsiness, nausea and vomiting in the observation group were lower than the control group (P<0.05). The analgesic effect rate was 93.1% (27/29) in the observation group, which was superior to 63.3% (19/30) in the control group (P<0.05). CONCLUSION: On the basis of oxycodone hydrochloride extended-release tablet, Miao medicinal crossbow acupuncture therapy as adjuvant treatment can effectively relieve the pain degree, reduce the number of break-out pain and improve the health status and quality of life in patients with lung cancer pain, enhance the efficacy of medication and reduce its adverse reactions.

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The management of a rare midclavicular crossbow bolt injury to the subclavian artery is discussed. Important concepts include the initial clinical diagnosis, operative planning, the surgical approach to the retro-clavicular great vessels, the technical aspects of repair, and postoperative course. A discussion of the reasoning behind an operative vs. endovascular approach is also discussed.

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OBJECTIVE@#To observe the clinical efficacy of Miao medicinal crossbow acupuncture therapy as adjuvant treatment for lung cancer pain based on oxycodone hydrochloride extended-release tablet.@*METHODS@#A total of 60 patients with lung cancer pain were randomized into an observation group (30 cases, 1 case dropped off) and a control group (30 cases). In the control group, oxycodone hydrochloride extended-release tablet was given orally, 10 mg a time, once every 12 hours. On the basis of the treatment in the control group, Miao medicinal crossbow acupuncture therapy was applied once every other day in the observation group. The treatment of 14 days was required in the two groups. Before and after treatment, the numerical rating scale (NRS) score, number of break-out pain and Karnofsky performance status (KPS) score were observed in the two groups. The equivalent oxycodone consumption and rate of adverse reactions were recorded, the analgesic effect was evaluated in the two groups.@*RESULTS@#Compared before treatment, the NRS scores and number of break-out pain were decreased while the KPS scores were increased after treatment in the two groups (P<0.01). After treatment, the NRS score and number of break-out pain in the observation group were lower than the control group (P<0.01), the KPS score in the observation group was higher than the control group (P<0.05). The equivalent oxycodone consumption of whole course and the rate of adverse reactions i.e. constipation, drowsiness, nausea and vomiting in the observation group were lower than the control group (P<0.05). The analgesic effect rate was 93.1% (27/29) in the observation group, which was superior to 63.3% (19/30) in the control group (P<0.05).@*CONCLUSION@#On the basis of oxycodone hydrochloride extended-release tablet, Miao medicinal crossbow acupuncture therapy as adjuvant treatment can effectively relieve the pain degree, reduce the number of break-out pain and improve the health status and quality of life in patients with lung cancer pain, enhance the efficacy of medication and reduce its adverse reactions.

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Penetrating neck injury by a crossbow bolt is extremely rare and can be life-threatening. When removing a crossbow bolt from the neck, it is necessary to protect against fatal bleeding from the carotid vessels. We report removing a crossbow bolt penetrating the neck, with an endovascular approach. A 49-year-old woman was shot in the neck by a crossbow and was transferred to our hospital. On presentation, the crossbow bolt totally penetrated the neck from right to left. Her level of consciousness was clear, with no significant neurological deficits except for right peripheral facial palsy. Neck contrast-enhanced computed tomography revealed the crossbow bolt in contact with bilateral external and internal carotid arteries and that the bolt caused dissection of the left main trunk of the external carotid artery. Under general anesthesia, the crossbow bolt was removed under fluoroscopy with the assistance of an endovascular approach. First, we performed coil embolization for the dissected external carotid artery. Second, we prepared for fatal bleeding from the carotid arteries during crossbow bolt removal under protection using guiding catheters placed in bilateral common carotid arteries. The bolt was removed successfully without significant bleeding, and no complications occurred during the procedure. We report the successful removal of a crossbow bolt penetrating the neck. When removing a crossbow bolt penetrating the neck, endovascular assistance may be feasible to protect against fatal bleeding from the carotid arteries.

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We are reporting the case of a 65 year-old man who suffered a severe depression and committed suicide using a crossbow. The death happened at his home. The suicide victim was on his knees, with of a crossbow leveled at his thorax and located facing him on the sofa. He shot it by pulling the trigger with the bended end of a ramrod. The arrow entered between the third and the fourth rib on the left side, with a downwards and slightly outwards direction. It went through the lung and the tip of the arrow came out the back. The arrow was removed when the body was lifted, and the wounds had a three-pointed star shape which corresponded to the head of the arrow crossbow. Police enquiry and forensic investigation confirmed a suicidal manner of death. This paper presents different issues of the case, such as the attestation of tears in clothing, the morphology of the wounds or the arrow track. The case is compared with other cases in the medical forensic literature involving the use of crossbows. Finally, it is highlighted how easy it is to purchase these weapons despite their obvious power and accuracy, factors that seriously recommend legislative regulation to be increased and its use more restricted.

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BACKGROUND: Penetrating crossbow head injuries are rare with no clear consensus regarding the optimal management paradigm for such injuries. We present three cases of crossbow injury to the head, with emphasis on the need for a comprehensive multidisciplinary management plan. CASE DESCRIPTION: Three cases are presented of patients presenting with self-inflicted penetrating crossbow to head injuries. All three patients presented with intact neurological exam. A comprehensive multidisciplinary plan was created for all three cases with subsequent successful removal of the arrows. All three patients were discharged home with modified Rankin scale score of <2. CONCLUSION: Penetrating crossbow brain injuries are rare and require complex management. A comprehensive management strategy is necessary to manage these injuries. Moreover, careful consideration of factors such as the arrow trajectory, complexity of the injuries, and availability of the required expertise is important to increase the chances of success.

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PURPOSE: To describe a case of a penetrating ocular trauma and plastic intraocular foreign body (IOFB), undetected on preoperative imaging. OBSERVATIONS: We present the findings of a 40-year-old male who sustained an open globe injury and IOFB composed of plastic following crossbow-related trauma. Preoperative detection of the IOFB was unsuccessful on clinical exam, computed tomography (CT) and ultrasonography. During extraction of the traumatic cataract, an intralenticular IOFB was discovered and removed through an enlarged limbal incision. Postoperative review revealed that a fragmented plastic "nock", from the crossbow arrow bolt, was the likely IOFB source. The bolt was produced by injection molding which may lead to trapped gas within the plastic, causing radiolucency on CT. CONCLUSIONS AND IMPORTANCE: Radiolucent plastic warrants consideration on the differential diagnosis when intraocular gas is noted on computed tomography following penetrating ocular trauma. Multimodal imaging should be considered if IOFB is suspected and not detected by CT.

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INTRODUCTION AND IMPORTANCE: Penetrating chest trauma caused by a crossbow bolt is very rare. Herein, we report a successfully treated patient who attempted suicide by directing a crossbow to the chest cavity and developed an expanding pseudoaneurysm of the thoracic aorta during eight-day follow up. CASE PRESENTATION: A 51-year-old male was admitted to the emergency department after firing a crossbow bolt twice into his left chest. At admission, the patient was hemodynamically stable and maintaining oxygenation. The bolt had already been removed from the body. Contrast-enhanced computed tomography (CT) revealed a cavity pseudoaneurysm 2.5 mm in size in the aortic arch. Three-dimensional reconstruction of the CT demonstrated wound tracts showing probable damage by the bolt. The patient was admitted to the emergency department for careful observation and transferred to the psychiatric ward on day two. Follow-up contrast-enhanced CT on day eight demonstrated rapid expansion of the pseudoaneurysm from 2.5 mm to 4.0 mm in size. We performed thoracic endovascular aortic repair (TEVAR) on day 13. The patient was uneventfully discharged on the 20th hospital day. CLINICAL DISCUSSION: Emergency physicians should be aware that damage to the surrounding tissue may be accompanied by delayed expansion of an aortic pseudoaneurysm, even if the bolts do not cause direct aortic wall injury. CONCLUSION: This case suggests that understanding the injury mechanism, confirming the tract of the bolts, and carefully exploring traumatic pseudoaneurysm can lead to a less invasive operation due to early detection.

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In modern times crossbow - a ranged weapon diffused during Middle Ages - is increasing its popularity in recreational hunting and sports; crossbow bolts have a great penetration capacity, despite their low initial velocity. Great concerns emerge when considering that notwithstanding crossbow is a potentially lethal distance weapon, it is easy to obtain without having to undertake any tests on the buyer's mental or physical health. Although rare, crossbow injuries can be challenging for the forensic pathologist due to great similarities with other wounds pattern (gunshots wounds or injury due to sharp force). Especially when the arrow is removed from its original position or the body is decomposed, identification of the weapon can be difficult. According to forensic literature, suicides, homicides and non-lethal injuries by crossbow have been reported up to the present day. We followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) indications in the identification and selection of studies and reviewed a series of cases of both fatal and non-fatal crossbow injuries, according to the manner of death (homicide, suicide, accidental). The casuistic part of this paper deals with an attempted murder of a 21-year old man: a case of non-lethal crossbow injury of the thorax in which an interdisciplinary approach, involving forensic inspection, ballistic and radiology tests, led to solve the case.

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BACKGROUND: Knee osteoarthritis (KOA) seriously reduces quality of life and is a major threat to the health of the middle-aged and elderly. This study aimed to assess the efficacy of Miao crossbow needle therapy vs. acupuncture for KOA therapy. METHODS: This multicenter, randomized controlled trial was performed at three hospitals between April 2016 and December 2016. The patients were randomized to receive crossbow needle (CN) or acupuncture (AT). All treatments were completed within 46 days. Evaluation of treatment was conducted on the 46th, 62nd, and 77th days. The primary endpoint was change of Western Ontario and McMaster Osteoarthritis Index (WOMAC) score on the 46th day. The secondary endpoints included WOMAC score, the Lysholm knee score, the Japanese Orthopedic Association (JOA) knee score, visual analog scale (VAS), and the MOS 36-item short-form health survey (SF-36), on the 46th, 62nd, and 77th day. RESULTS: Finally, data of 301 participants were analyzed for the efficacy of treatment. Compared with AT, there was a larger change of WOMAC score in the CN group after treatment [- 25.0 (95% CI - 27.0, - 23.0) vs. - 18.8 (95% CI - 20.8, - 16.9), P < 0.001]. In the CN group, the WOMAC score was lower at all three time points (P = 0.008, P = 0.003, P < 0.001 respectively), while the Lysholm knee score (P = 0.03) and JOA score (P = 0.013) were higher and the VAS score (P = 0.011) was lower on the 77th day. CONCLUSION: Both Miao crossbow needle therapy and acupuncture reduced the WOMAC score. Miao crossbow needle therapy can be an alternative method for treating patients with knee osteoarthritis. TRIAL REGISTRATION: ChiCTR, ChiCTR-INR-16008032. Registered on 12 March 2016.

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Traumatic injury due to crossbows is a rare occurrence these days. The aim of this study is to present a case of perforating chest injury caused by a bolt shot from a crossbow in suicidal intent which occurred “live“ during a telephone conversation. The autopsy revealed perforation of the heart and left lungs with massive bleeding to the left pleural cavity which caused haemorrhagic shock. The motive of the mans suicide was the breakup with his girlfriend.

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We report the successful repair in a 29-year-old man who experienced penetration of the ascending aorta and bronchus by a crossbow bolt. Imaging studies revealed the arrow penetrating the sternum, right lung, ascending aorta and right bronchus, with mediastinal emphysema. The top of the arrow (8 mm in diameter) was deeply embedded in the body of the thoracic vertebra. The arrow was successfully removed while maintaining a stable respiratory condition by performing differential lung ventilation. There was no need for cardiopulmonary bypass. To our knowledge, this is the first case of a through-and-through penetrating ascending aorta injury.

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INTRODUCTION: Airway management and control of bleeding are essential aspects of the management of attempted suicide involving the head and neck. Attempted suicide using a crossbow is exceptional. The patient's respiratory status, the position of the crossbow bolt in the head and neck, the type of bolt and its exit wound required airway management that has not been previously reported in the literature. CASE REPORT: This conscious patient had attempted suicide by shooting a crossbow bolt to the head. The radiological assessment (contrast-enhanced CT scan) did not reveal any vascular, ophthalmological or neurological lesions. The submental entry wound of the bolt avoided any damage to the lingual and ethmoidal arteries, lamina papyracea, or frontal lobe. The bolt induced mechanical trismus and its position limited access to the base of the neck, preventing orotracheal intubation. Nasotracheal intubation and primary tracheotomy were also difficult in this situation. It was therefore decided to remove the bolt while the patient was still conscious, rapidly followed by intubation, with no complications. CONCLUSION: In attempted suicide by crossbow involving the head and neck, airway management depends on the possibility of exposure of the glottis, the bolt exit wound and safe access to the anterior neck.

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In recent times, the number of criminal incidents involving crossbows in the UK has increased with many incidents resulting in either injuries or fatalities. Whilst the effects of crossbow bolts on the body are well understood, there is a limited understanding on how these projectiles interact with the wider environment. One area of particular interest is the interaction between common vehicle side windows and bolts. In this study, the penetrability of two distinct bolts using an off-the-shelve crossbow against a common automotive side window was explored, where velocity loss up to 25 m/s post impact was recorded. All windows failed through radial glass fracture at a rate up to 1600 m/s, whilst bolt damage varied from tip holder decoupling, shaft damage, and traumatic fletching removal. No distinct relationship between bolt type, velocity, and window damage was identified.

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