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CASE REPORT Table of Contents   
Year : 2011  |  Volume : 8  |  Issue : 1  |  Page : 101-104
Vulnerability of children to gunshot trauma in violence-prone environment: The case of South Africa

Department of Paediatric Surgery, Child Accident Prevention Foundation of Southern Africa, Red Cross Children's Hospital, University of Cape Town, Rondebosch, Cape Town, South Africa

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Date of Web Publication6-Apr-2011


South Africa has a high level of violence, as more people are killed by gunfire each year than in motor vehicle accidents, and the numbers are increasing. Regrettably, children are affected most by this epidemic. During 1997, a total of 142 children aged less than 14 years died from gunshot injuries while many more were injured.
Here we present the case of an 11-year-old male street child who sustained a gunshot to the face, and illustrate the magnitude of the problem.
The escalating epidemic of firearm-related injuries and deaths among children and adolescents in Cape Town, like in many other parts of the world, calls for concern. Further research is needed to understand firearm-related injuries among children and adolescents in South Africa, and to develop policies and programmes for effective prevention of situations such as this.

Keywords: Children, gunshot wounds, head, mandible

How to cite this article:
Naidoo S, Van As A B. Vulnerability of children to gunshot trauma in violence-prone environment: The case of South Africa. Afr J Paediatr Surg 2011;8:101-4

How to cite this URL:
Naidoo S, Van As A B. Vulnerability of children to gunshot trauma in violence-prone environment: The case of South Africa. Afr J Paediatr Surg [serial online] 2011 [cited 2020 May 30];8:101-4. Available from:

   Introduction Top

In South Africa, the sociopolitical environment has had a deleterious effect on the economic and social environment in which the majority of the population live. The country also has a high level of violence-more people are killed by gunfire each year than in motor vehicle accidents (MVAs), and the numbers are increasing. [1] Regrettably, children are most affected by this epidemic. In the US, only MVAs and cancer claim children's lives more than firearms do. [2] In 1997, a total of 142 children aged under 14 years died from gunshot injuries, [3] while many more were injured. Studies conducted both in South Africa and the US show a yearly increase in the number of gunshot injuries affecting children. [4],[5],[6] Although different age groups have different risks, the vast majority of gunshots occur in the age group of 13-19 years. [7],[8] Furthermore, a significant number of gunshots are now seen among children younger than 13 years, and the incidence continues to increase. [4],[9] Most of the children have been shot accidentally.

Children may be at an increased risk of head and intra-abdominal injury due to their relatively large head proportion, and poorly protected abdominal contents. [10] In a recent study at the Red Cross Hospital, 60% of admissions to the intensive care unit (ICU) had head injuries; also, of the 53 gunshots to the head region, 23 caused injury to the face, 13 injured soft tissue, 5 involved fractures, and 5 were ophthalmic injuries. Of the head injuries, 5 involved soft tissue, 7 sustained an associated bone fracture, and 18 involved intracranial structures. [11]

The ability to acquire guns-legally or illegally-is not the only factor reflecting the presence and prevalence of gunshots wounds in a population, but is related to a variety of complex determinants. Factors that play a role include the attitude of the society on the use of violent force, society's social, political and moral maturity, as well as the geographical layout of housing in residential areas. As a result of interactions among these factors, gunshot injuries are often a manifestation of underlying social problems within communities.

The situation in South Africa may not be directly comparable with that in many other countries. However, there is clear evidence that countries with relaxed attitudes to gun control have higher numbers of paediatric gunshot injuries and deaths. [2],[3],[12] Furthermore, as the majority of children suffer accidental injury - either caught in the crossfire, or playing with guns in the house [13] - a reduction in availability of firearms should be the goal of those working at injury prevention. The mean age of children shot in Kwazulu-Natal between 1983 and 1995 was 6.4 years. [9] Suicide by shooting in not common among South African youth. [14]

In South Africa, there is a paucity of research on the epidemiology of firearm injuries affecting younger children, information on the prevalence of firearms in the community, and the sources from which they are procured.

   Case Report Top

An 11-year-old male street child was admitted to the Red Cross Children's Hospital Trauma Unit at 2300 h on April 20, 2006. He had sustained a gunshot in the face, with the bullet entry wound in the left cheek, just above the left side of the upper lip. The entire left side of the face was swollen and the occlusion deficient. Two bullet fragments were palpated subcutaneously in the left posterior triangle of the neck.

Despite haemoptysis, the airway was not compromised and there was good air entry over both bilateral lung fields. Haemodynamically he was stable, with blood pressure, 144/77 mmHg; pulse rate, 86 beats per minute; and haemoglobin level, 9.6 g%.

Radiographs demonstrated a left-sided comminuted compound fracture of the mandible, with shrapnel lodged diffusely in the soft tissues of the left cheek [Figure 1] and [Figure 2]. He was given prophylactic intravenous antibiotic therapy and prepared for surgery.
Figure 1: Lateral and anteroposterior radiographs of the mandible with the mandibular fracture and bullet shrapnel clearly visible.

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Figure 2: Lateral and anteroposterior radiographs of the mandible with the mandibular fracture and bullet shrapnel clearly visible.

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In the operation theatre, extensive debridement of the wound was performed, with the removal of several bullet fragments and shrapnel from the casing. An open reduction of the mandibular fracture was performed followed by internal fixation of the left mandible [Figure 3].
Figure 3: Postoperative lateral radiograph of the mandible after internal fixation.

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The postoperative course was uncomplicated until day 3, when the patient discharged himself back on to the street.

   Discussion Top

Studies conducted on gunshot injuries have shown that most injuries are caused by low-velocity civilian handguns, and that mandibular fractures were more common than maxillary fractures. [15],[16],[17] More than a third of patients require endotracheal intubation or tracheostomies, especially in cases where the lower third of the face and neck are affected. [18] The fractures are mostly comminuted and treated conservatively by closed reduction and inter-maxillary fixations. The most commonly reported complications are sepsis, limitation of mouth opening, and bony and soft-tissue residual defects. [18]

There is a wealth of evidence linking gun ownership levels with paediatric gunshot-related mortality. [2],[3],[12] In a recent study in the US among 5- to 14-year-olds, children living in the US with high levels of gun ownership were 16 times more likely to die from unintentional firearm injury. The same study further showed that lower gun ownership levels were not related to increased levels of non-firearm-related deaths. Furthermore, there is good evidence to suggest that parents will change their decision to keep a gun in the home if they are persuaded of the merits of doing so by a medical practitioner. [19]

   Conclusions Top

The only rational approach to gunshot injuries in children is prevention. Prevention is everybody's business: legislation to reduce the availability of guns should help in reducing the cases of death and injury. [2] Unintentional firearm-related deaths among children have been declining steadily in the US due to an increase in Child Access Prevention (CAP) laws. [20] A study conducted in the US revealed that parents can be dissuaded from keeping a gun in the house if so advised by their paediatrician. [19] Where there is great resistance to reducing gun ownership, as with many powerful lobbies in the US, alternative methods to effect injury prevention may include trigger locks and personalisation. [21]

While the evidence against uncontrolled ownership of guns mounts, and children continue to be injured or killed by bullets, pressure is increasing on the medical fraternity to improve surveillance of gunshot injuries, [22],[23],[24] improve preventative strategies, [25] and pass legislation. [3],[4],[12],[21] In Africa, guns are a way of life and children should be made aware of their dangers. The tragic consequences for children of the presence of firearms in the society are increasing worldwide. [5],[26],[27] In South Africa in 2004, there were 4.5 million registered firearms, including 2.8 million handguns. Additionally, there were an estimated 500,000 to 1 million illegal firearms in circulation; one firearm for every eight to nine South Africans. [28] While powerful lobbies continue to debate gun control across the world, our children are dying. In South Africa, all healthcare professionals should lobby the government at all levels for legislation to reduce gun ownership, impose tougher penalties on offenders, and protect our children from this increasing epidemic.

   References Top

1.Burrows S. A profile of fatal injuries in South Africa 2000: Second annual report of National Injury Mortality Surveillance System. Johannesburg: 2001.   Back to cited text no. 1
2.Miller M, Azrael D, Hemenway D. Firearm availability and unintentional firearm deaths, suicide and homicide among 5-14 year olds. J Trauma 2002;52:267-74.  Back to cited text no. 2
3.Webster DW, Starnes M. Reexamining the association between child access prevention gun laws and unintentional shooting deaths of children. Pediatrics 2000;106:1466-9.  Back to cited text no. 3
4.Wigton A. Firearm related injuries and deaths among children and adolescents in Cape Town. S Afr Med J 1999;89:407-10.  Back to cited text no. 4
5.Barlow B, Niemirska M, Gandhi RP. Ten years′ experience with pediatric gunshot wounds. J Pediatr Surg 1982;17:927-32.  Back to cited text no. 5
6.Kassan AH, Lalloo R, Kariem G. A retrospective analysis of gunshot injuries to the maxillo-facial region. S Afr Dent J 2000;55:359-63.  Back to cited text no. 6
7.American Academy of Pediatrics Committee on Injury and Poison Prevention: Firearm injuries affecting the pediatric population. Pediatrics 2000;105:888-95.  Back to cited text no. 7
8.Knight-Bohnhoff K, Burkybile D. Deaths from firearms among children and adolescents in New Mexico. Am J Public Health 1995;85:872.  Back to cited text no. 8
9.Hadley GP, Mars M. Gunshot injuries in infants and children in Kwazulu-Natal - an emerging epidemic? S Afr Med J 1998;88:444-7.  Back to cited text no. 9
10.Advanced Life Support Group. Advanced Paediatric Life Support. London: BMJ Publishing Group; 2001.  Back to cited text no. 10
11.Van As AB, Hutt J, Wallis L, Numanoglu A, Millar AJ, Rode H. Gunshot wounds in children: Epidemiology and outcome: African Safety Promotion. J Injury Violence Prev 2004;2:4-15.  Back to cited text no. 11
12.Beaver BL, Woo S, Voigt RW, Moore VL, Smialek J, Suter C, et al. Does handgun legislation change firearm fatalities? J Pediatr Surg 1993;28:306-8.  Back to cited text no. 12
13.Jackman JA, Farah MM, Kellermann AL, Simon HK. Seeing is believing: What do boys do when they find a real gun? Pediatrics 2001;107:1247-50.  Back to cited text no. 13
14.Van der Heyde Y. Causes of death in children under 14 years in 2001. M Med Path (Foren) Thesis. University of Cape Town; 2003.  Back to cited text no. 14
15.Bamjee Y, Lownie JF, Cleaton-Jones PE, Lownie MA. Maxillo-facial injuries in a group of South Africans under 18 years of age. Br J Oral Maxillofac Surg 1996;34:298-302.  Back to cited text no. 15
16.Taher AA. Management of weapon injuries to the cranio-facial skeleton. J Craniofac Surg 1998;9:371-82.   Back to cited text no. 16
17.Cohen MA, Shakenovsky BN, Smith I. Low velocity hand-gun injuries of the maxillo-facial region. J Maxillofac Surg 1986;14:26-33.  Back to cited text no. 17
18.Haug RH. Management of low calibre, low velocity gunshot wounds of the maxillo-facial region. J Oral Maxillofac Surg 1989;47:1192-6.  Back to cited text no. 18
19.Webster DW, Wilson ME, Duggan AK, Pakula LC. Parents′ beliefs about preventing gun injuries to children. Pediatrics 1992;89:908-14.  Back to cited text no. 19
20.Hepburn L, Azrael D, Miller M, Hemenway D. The effect of child access prevention laws on unintentional child firearm fatalities, 1979-2000. J Trauma 2006;61:423-8.  Back to cited text no. 20
21.Teret SP, Webster DW. Reducing gun deaths in the United States. BMJ 1999;318:1160-1.  Back to cited text no. 21
22.Rosenberg ML, Hammond WR. Surveillance: The key to firearm injury prevention. Am J Prev Med 1998;15:1.  Back to cited text no. 22
23.Frattaroli S, Teret SP. Why firearm injury surveillance? Am J Prev Med 1998;15:2-4.  Back to cited text no. 23
24.Kellermann AL, Bartolemeos KK. Firearm injury surveillance at the local level: From data to action. Am J Prev Med 1998;15:109-11.  Back to cited text no. 24
25.Christofel KK, Longjohn MM. Gun injury prevention comes of age. J Trauma 2002;53:213-8.  Back to cited text no. 25
26.Dokucu AI, Otcu S, Ozturk H, Onen A, Ozer M, Bukte Y, et al. Characteristics of penetrating abdominal firearm injuries in children. Eur J Pediatr Surg 2000;10:242-7.  Back to cited text no. 26
27.Letts RM, Miller D. Gunshot wounds of the extremities in children. J Trauma 1976;16:807-11.  Back to cited text no. 27
28.Available from: [last accessed on 2007 Jan 5].  Back to cited text no. 28

Correspondence Address:
A B Van As
Department of Paediatric Surgery, Red Cross Children's Hospital, University of Cape Town, Rondebosch 7701, Cape Town
South Africa
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0189-6725.79070

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  [Figure 1], [Figure 2], [Figure 3]

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