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Dogma Bust – Paperclips in Penetrating Trauma

April 1, 2024

Written by Clark Strunk

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The use of radiopaque markers (ROM) in penetrating trauma is based on expert opinion and historical clinical practice; however, there is no high-quality evidence to support their routine use in clinical practice.

Quick! Grab the paperclips!
This article provides commentary on the use of ROM in penetrating trauma. The authors first review the historical context of this practice where it may have had some utility in certain practice settings with limited access to advanced imaging modalities. They also discuss the multiple factors that affect the trajectory of ballistics such as the type, size, velocity, and potential for ricochet. These factors can lead the bullet to deviate from its anticipated course and can lead to injury to structures that might not be on the suspected path between the ROMs. Furthermore, ROM can cause artifact and degrade the quality of certain imaging studies. Finally, the authors conclude that the use of ROM in penetrating trauma is not evidence based and has become medical dogma.

How will this change my practice?
In my current practice environment, the use of ROM is routine, and I do not see that changing anytime soon. Although I do not believe that there is significant harm when utilizing ROM in the assessment of patients with penetrating trauma, I also don’t think they provide useful diagnostic information. Consequently, if ROM are readily available and will not impede the clinical evaluation and treatment of a patient with penetrating trauma, I will likely continue to use them; however, if there is a paperclip shortage at my hospital, I don’t believe there will be a decline in the care patients receive.

The use of radiopaque markers is medical dogma. Acad Emerg Med. 2024 Feb;31(2):193-194. doi: 10.1111/acem.14858. Epub 2024 Feb 6.

What are your thoughts?