Medicolegal Investigation of Gunshot Wounds: A Narrative Review

Firearm-related deaths are a significant medicolegal and public health concern worldwide, with prevalence varying by region. In the United States, gunshot wounds are a leading cause of violent death, whereas stricter firearm regulations in most European and Asian countries result in fewer firearm fatalities, with sharp or blunt instruments more commonly implicated. This narrative review provides a foundational overview of firearm-related fatality pathology, targeting pathology residents, forensic pathology fellows, and practicing forensic pathologists. Emphasis is placed on essential ballistic concepts, terminology, and wound classification rather than exhaustive firearm mechanics. Key topics include the differentiation of entrance, exit, graze, and tangential wounds; the role of temporary and permanent cavities in tissue damage; and features relevant to range-of-fire estimation, such as soot, stippling, and burns. Special considerations are addressed, including ricochet injuries, keyhole defects, tandem bullets, bullet embolism, retained projectiles, and the ability to act following head injuries. The review also highlights the importance of meticulous documentation, projectile recovery, and trajectory assessment for both autopsy reporting and court testimony. Forensic pathologists in regions with lower firearm incidence can face unique diagnostic challenges in interpreting atypical cases. Familiarity with these fundamental principles ensures preparedness, particularly in regions where firearm fatalities are uncommon, allowing pathologists to approach even rare cases with confidence, accuracy, and professional rigor.