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Face value?
  1. R Bethune,
  2. E Hern,
  3. A Qayyum,
  4. R Pratap,
  5. R Brown
  1. Accident and Emergency Department, St Mary’s Hospital, Paddington, London, UK
  1. Correspondence to:
 Dr R Bethune
 Accident and Emergency Department, St Mary’s Hospital, Paddington, London, UK; rob.bethunedoctors.net.uk

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A 13 year old boy presented to accident and emergency with his mother. He claimed he had fallen, hitting his nose on the pavement. His initial epistaxis settled and he was left with a small laceration on the side of his right nostril (see fig 1). There was no swelling or trismus and the general examination was normal. The attending doctor was called away and on return noticed a swelling over his left check, which was now mildly tender. Radiographs were performed at this point (fig 2A and B). The boy still denied any other history despite being shown the radiographs. Eventually the mother was persuaded to leave the room and it was only then that the child admitted to being shot in the face with an altered blank bullet, while playing with his friends.

Figure 1

 Photography one day after injury.

Figure 2

 (A) AP and (B) lateral radiographs.

A subsequent CT scan showed the bullet lying superomedial to the cornoid process of the left mandible. It had passed through the nasal septum and both walls of the left maxilla. His symptoms settled completely and his lead levels remained constant, so the decision was to leave the bullet in place as it often is.1

The main lesson to draw from the case was, despite the seriousness of the incident, young adolescents often withhold crucial information when a parent or guardian is present. Thus in some situations a more accurate history can be obtained with the child alone.2

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