Clinical and legal significance of fragmentation of bullets in relation to size 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 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.