Assessment of bullet disruption in armed conflicts.

Under international humanitarian law, the Hague Declaration of 1899 forbids the use of small arms ammunition that disrupts in the body after impact. However, assessment of whether bullets have undergone disruption is subjective and accusations that one or both sides of a conflict have used such ammunition cannot be substantiated. We describe a method by which disruption of bullets after impact can be assessed objectively. We reviewed 1287 wound radiographs of 1201 patients in four International Committee of the Red Cross hospitals. Radiographs were scored according to the F (fracture) and M (presence of metallic bodies) variables of the Red Cross wound classification; bullet disruption is evidenced by metallic fragments on the radiograph. One hospital had a significantly higher proportion of patients wounded by bullets that disrupted after impact; these wounds were associated with comminuted fractures. The findings show that the presence of metallic fragments on a radiograph is a reliable indicator of wound severity and bullet disruption. The study has important implications for the upholding of international humanitarian law, because with our method the use and manufacture of bullets that contravene the Hague Declaration can be identified.