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

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 a dmissions. 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 clas sification and presence of bullet fragments on radiography. Results Of the 347 wounds with fragmentation of bullets, 251 (72%) were lar ge 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 lar ge wounds. Only 7.9% (251/3166) of large wounds were associated with fragme ntation of bullets. Conclusions Fragmentation of bullets is associated with large wounds, but m ost large wounds do not contain bullet fragments. In addition, bullet fragm ents may occur in wounds that are not defined as large. Fragmentation of bu llets is neither a necessary nor sufficient cause of large wounds, and surg eons should not diagnose extensive tissue damage because of the presence of fragments on radiography Such findings also do not necessarily represent t he use of bullets which contravene the law of war. Future legislation shoul d take into account not only the construction of bullets but also their pot ential to transfer energy to the human body.