Clinical and legal significance of fragmentation of bullets in relation to size of wounds: retrospective analysis

Abstract

Objective: To examine the relation between fragmentation of bullets and size of wounds clinically and in the context of the Hague Declaration of 1899.

Design: Retrospective analysis of prospectively collected data on hospital admissions.

Setting: Hospitals of the International Committee of the Red Cross.

Subjects: 5215 people wounded by bullets in armed conflicts (5933 wounds).

Main outcome measures: Grade of wound computed from the Red Cross wound classification and presence of bullet fragments on radiography.

Results: Of the 347 wounds with fragmentation of bullets, 251 (72%) were large wounds (grade 2 or 3)-that is, those with a clinically detectable cavity. Of the 5586 wounds without fragmentation of bullets, 2915 (52.1%) were large wounds. Only 7.9% (251/3166) of large wounds were associated with fragmentation of bullets.

Conclusions: Fragmentation of bullets is associated with large wounds, but most large wounds do not contain bullet fragments. In addition, bullet fragments may occur in wounds that are not defined as large. Fragmentation of bullets is neither a necessary nor sufficient cause of large wounds, and surgeons should not diagnose extensive tissue damage because of the presence of fragments on radiography. Such findings also do not necessarily represent the use of bullets which contravene the law of war. Future legislation should take into account not only the construction of bullets but also their potential to transfer energy to the human body.

Figure 1

Bullet wound of left thigh. Top: Entry wound is indicated by pen and measured <1 cm. Exit wound on lateral side of thigh is large and obvious. Bottom: Radiograph shows comminution of femur with one large and several small metallic bullet fragments. Wound is grade 2 (scores: E=1, X=8, C=1, F=2, V=0, M=2)

Figure 1

Bullet wound of left thigh. Top: Entry wound is indicated by pen and measured <1 cm. Exit wound on lateral side of thigh is large and obvious. Bottom: Radiograph shows comminution of femur with one large and several small metallic bullet fragments. Wound is grade 2 (scores: E=1, X=8, C=1, F=2, V=0, M=2)

Figure 2

Bullet wound of left arm. Top: Entry wound is just proximal to elbow joint and is indicated by forceps in surgeon’s hand. Exit wound in forearm is large and obvious. Bottom: Radiograph shows comminution of forearm bones and no metallic bullet fragments. Wound is grade 3 (scores: E=1, X=11, C=1, F=2, V=0, M=0)

Figure 2

Bullet wound of left arm. Top: Entry wound is just proximal to elbow joint and is indicated by forceps in surgeon’s hand. Exit wound in forearm is large and obvious. Bottom: Radiograph shows comminution of forearm bones and no metallic bullet fragments. Wound is grade 3 (scores: E=1, X=11, C=1, F=2, V=0, M=0)