Injuries caused by rubber bullets: a report on 90 patients

Risks and regulation of rubber scattershot in Switzerland: a narrative review

Multiple kinetic impact projectiles (KIPs) are responsible for most eye injuries by crowd-control weapons. This review aims to outline an underreported, ongoing series of eye injuries by rubber scattershot in Switzerland, and to relate current knowledge about thresholds for lasting visual loss to the energy limits set on KIPs in crowd control, by way of a retrospective compilation of cases from publicly available records and a review of the pertinent literature. Scattershot can cause irreversible visual loss. Since 1980, there have been 36 known cases of eye injuries by rubber pellets in Switzerland. In 2023, the incidence was higher here than at the peak of protests in France. KIPs were originally cleared for use in crowd control at kinetic and area-normalised energies assumed to lie below the threshold for ocular penetration. However, closed globe injuries suffice to cause permanent visual loss. Lower energy thresholds for lasting damage have been confirmed by the newer literature on paintballs, airbags, air guns and toys. These values may differ in vivo versus in vitro, and in humans versus in animals. There is no clear consensus on how best to predict loss of vision. Underreporting the risks of crowd-control weapons may contribute to their prolonged and increasingly liberal use. Regulations should consider what is known on energy thresholds for permanent visual loss. It is critical for ophthalmologists to be involved in the evaluation and monitoring of eye injuries caused by projectiles, including KIPs and toys. An interdisciplinary approach could help to elucidate damage thresholds.

Assessment of injuries patterns produced by a 9mm P.A.K "rubber ball" blank firing weapon: porcine model

The use of less lethal weapons aims to mitigate civilian casualties caused by firearm use. However, due to numerous cases in which these weapons caused serious injuries, even lethal injuries, both legislation and the forensic field are interested in characterizing and regulating them better. In the forensic field, there is a lack of strong research about injury patterns of these weapons which makes it difficult to identify the type of weapon employed. In this study, the main objective was to characterize the injury pattern produced by the impact of the 9 mm P.A.K. projectile. A porcine model was used. Four different distances were studied: firm contact, 10 cm, 60 cm and 110 cm, using 3 of the more representative anatomical sites: the head, the hind leg and the ribs. The average measurement of the entrance orifice varied according to the anatomical site, being 6.67 mm wide and 6.25 mm long in the thorax, 7.3 mm wide and 8.8 mm long in the hind legs, and 7.62 mm wide and 7.54 mm long in the head. The variation in width and length measurements was not found to be directly related to the shot distance. The gunshot residues had similar characteristics to those of conventional lead projectiles, however there was more unburned powder deposit near the wounds, with a less dense soot and more dense powder tattoo. Depth varied widely regardless of tissue and firing distance, although loss of penetrating power and injury is observed as one moves away from the target.

Lesiones mortales por armas traumáticas: reporte de caso

Introducción. Las armas de energía cinética son diseñadas para generar lesiones dolorosas y superficiales. Sin embargo, las lesiones asociadas causan confusión al ser abordadas como heridas por proyectil de arma de fuego, convirtiendo el enfoque y el manejo correcto en un desafío. El caso presentado describe un paciente herido en el cuello por arma traumática con el objetivo de analizar factores que permitan identificar este tipo de heridas y sus implicaciones en el manejo. Caso clínico. Paciente masculino de 31 años que ingresó con intubación orotraqueal, remitido de una institución de nivel 2, con herida por aparente proyectil de arma de fuego con trayectoria transcervical. Se encontró hemodinámicamente estable, pero con dificultad para la valoración clínica, por lo que se realizaron exámenes complementarios que descartaron lesión aerodigestiva. La tomografía de cuello reportó proyectil alojado en musculatura paravertebral izquierda, descartando trayectoria transcervical. Discusión. El comportamiento de las lesiones asociadas a los proyectiles de armas depende de varios factores, como el tipo de material del proyectil, su velocidad y las propiedades del tejido impactado. Se presentó un caso en que inicialmente se sospechaba una lesión transcervical, pero con la evaluación se identificó el proyectil cinético en la musculatura paravertebral. Conclusión. En el abordaje de un paciente con sospecha de herida por proyectil de arma de fuego se debe considerar ante todo la respuesta clínica y la correlación del supuesto vector del proyectil con las lesiones sospechadas. La evaluación imagenológica permite identificar oportunamente los proyectiles y evitar procedimientos o terapias innecesarias que forman parte del manejo convencional del paciente con trauma penetrante.

Death and non-lethal weapons: A case of homicide by penetrating injury without projectile

Herein, we report the death of a man, approximately thirty years old, victim of a short-range shot to the thorax from a PIEXON JPX4, a hand weapon classed category D in France, said to be non-lethal. External examination of the lesion revealed characteristics similar to those of ballistic injuries. The autopsy found an intercostal wound that reached the pulmonary parenchyma and the pulmonary artery, with severe hemothorax. By the end of the autopsy, no projectile had been found in the body, nor any exit orifice. Death was caused by the effects of hemorrhagic shock. The PIEXON JPX4 has four cartridges, projecting a capsaicin gel that is designed to irritate the ENT area (ear nose throat) to incapacitate an assailant. The manufacturer recommends not to use it at distances of less than 1.5 m. Experimental shots were performed on gelatine blocks at point-blank range and at distances of 5, 10, 20, 30, 50, 100 and 150 cm to evaluate the distance necessary for the jet of gel to have a penetrating effect. Shots at 5-30 cm penetrated the structure. None of the other shots were penetrating. The autopsy and experiment data therefore show the penetrating potential of the jet of gel. Herein, we report the first death due to use of the PIEXON JPX4. From a forensic investigation viewpoint, we add a new exception to the "bullet rule". (The odd and even bullet rule states that if the number of gunshot wounds of entrance and exit found in the body is even, the presumption is that no bullet is lodged in the body. If the number of gunshot wounds of entrance and exit is odd, the presumption is that one or more bullets have been lodged in the body.).

Ocular injuries from drive-by paintball shootings

PURPOSE

To characterize ocular injuries from drive-by paintball shootings with a focus on the severity of injuries sustained, clinical management, and visual outcomes.

DESIGN

Retrospective, interventional case series.

METHODS

Setting: University practice and emergency department.

PATIENT POPULATION

Patients evaluated by the ophthalmology service for paintball injuries.

OBSERVATION PROCEDURE

Age, gender, eye laterality, mechanism of injury, initial best-corrected visual acuity (BCVA), and initial diagnosis.

MAIN OUTCOME MEASURES

Clinical intervention(s), BCVA at last follow-up visit, and severity of injuries with a focus on ruptured globes.

RESULTS

Twenty patients suffered unilateral ocular injuries from drive-by paintball shootings between January 2020 and December 2021. Median follow-up interval was 7.1 weeks (range: 3 days - 11.4 months). Average patient age at presentation was 36.6 years (range: 13 - 64 years-old). Fourteen patients (70%) had an initial BCVA of counting fingers (CF) or worse. Six patients (30%) suffered ruptured globe injury requiring surgical repair, of whom three (15%) underwent subsequent evisceration. Twelve patients (60%) suffered ocular injuries requiring surgical intervention. Fifteen ocular surgeries were performed on 9 patients (45%) at our institution with 3 patients referred to outside providers for definitive surgical management due to insurance. BCVA at last-follow up visit was no light perception (NLP) in five patients.

CONCLUSIONS

The severity of injury following paintball-induced ocular trauma is higher in this case series than what has previously been reported in the literature. Paintball guns can cause devastating ocular injury when used as an assault weapon and their use in unregulated settings bears further scrutiny.

Rubber Bullet Induced Traumatic Brain Injury

ABSTRACT

Rubber bullets have long been known to cause, on rare occasions, traumatic brain injury (TBI). However, neurosurgical literature on this occurrence is limited, and no focused review of this injury pattern has been conducted. The authors present the case of a 28-year-old male struck by a rubber bullet in the left periorbital region, causing TBI in addition to complete left visual loss and complex facial fractures. After developing a cerebrospinal fluid (CSF) leak, the patient was taken to the operating room for combined neurosurgical-craniofacial intervention. Utilizing frameless intraoperative computation tomography navigation assistance, a successful repair was made of both the patient's CSF leak and complex craniofacial injuries. TBI due to a rubber bullet is a rare but severe occurrence. Unfortunately, much of the limited literature on this topic is bereft of demographic, clinical course, injury pattern, and imaging data. Presented here is the first operative case report of TBI due to a rubber bullet. Volume rendered imaging is provided to demonstrate the extent of trauma incurred. Additionally, a methodology for frameless intraoperative computation tomography navigation assistance is shared for consideration, as it served as a helpful adjunct for a combined intracranial-craniofacial surgical repair. The experience of treating the patient's traumatic CSF leak in the context of severe craniofacial and ophthalmologic injuries highlights the need for a multidisciplinary surgical approach that may arise when treating patients with TBI due to a rubber bullet.

Ocular trauma by kinetic impact projectiles during civil unrest in Chile

Background

The use of kinetic impact projectiles (KIPs) for crowd-control has increased worldwide. Despite having been created as non-lethal weapons, significant damage to several organs, including the eye, has been reported. In this study, we investigated cases of ocular trauma from KIPs during the civil unrest in Chile. To our knowledge, this is the largest case series recorded in international literature.

Methods

We included all patients who sought care or were referred to the Eye Trauma Unit, a national referral centre in Santiago, Chile, during the civil unrest from October 18 to November 30, 2019. We reviewed paper medical records and extracted data on suspected cause of trauma, type of trauma, visual acuity and sociodemographic data.

Results

We included 259 patients, out of which in 182 cases (70.5%) KIPs were the suspected cause. Cases by KIPs were predominantly male (86.6%), young (median age 26.3, interquartile range 22.0–31.4) and living in the Metropolitan Region. Eighty-nine patients (48.9%) had severe visual impairment or were blind at the first examination. The trauma was an open-globe injury in 20.3% of cases and 13 cases required evisceration of the ocular content. Compared to other causes of ocular trauma, KIPs were related to a more severe loss of visual acuity and a higher frequency of open-globe injuries.

Conclusions

The use of KIPs during a period of civil unrest in Chile resulted in severe ocular trauma, visual impairment and permanent disability. KIPs should be avoided as a method of crowd-control.

Less-Lethal Weapons Resulting in Ophthalmic Injuries: A Review and Recent Example of Eye Trauma

Introduction

Prior reports have highlighted the dangers of crowd control weapons such as rubber bullets, paintball guns, and pepper spray. Many of these reports were written decades ago and outside of the USA. We summarize a review of the literature and discuss a contemporary case of a ruptured globe and facial trauma secondary to a projectile weapon. This case serves to highlight the severity of eye trauma caused by less-lethal weapons; severe morbidity or even mortality can occur.

Clinical Description

A civilian presented after a projectile weapon reportedly fired by Denver law enforcement struck his face during one of the recent protests in May 2020 in Denver. Upon ophthalmic examination, we observed no light perception (NLP) vision, periorbital ecchymosis, and devastating globe trauma.

Primary Diagnosis, Interventions, and Outcomes

Further examination revealed a severely ruptured globe with extensive hemorrhage and extrusion of intraocular contents. Attempts to repair the ruptured globe failed because of the lack of remaining scleral tissue and expulsion of intraocular contents. Postoperatively, the visual acuity remained NLP and the eye was unable to hold pressure. Subsequently, the patient elected for enucleation.

Conclusion

Despite the purported safety advancements of less-lethal weapons, we continue to see high levels of morbidity and mortality. Permanent vision loss, loss of the eye, and death caused by these weapons have been reported. We hope that this information will serve as an example to help promote judicious use of these weapons by the proper authorities. Additionally, protesters and bystanders should be aware of these dangers and utilize high-quality eye protection.

Suicidal shot in the mouth with rubber bullets

Rubber bullets weapons can have tragic consequences when used at short range and on vulnerable body areas. A man in his forties was found deceased at his house, covered in blood. A "non-lethal" firearm was found near the bed: the «SAPL GC27». This is a single shot handgun with mini Gomm Cogne ammunition: 12 rubber spherical pellets, 7.4 mm in diameter. The findings were consistent with an intra buccal shot, and an ingestion-inhalation of blood and projectiles. Cause of the death was linked to both the hemorrhage due to mouth and aero digestive crossroad trauma, responsible of a mechanical asphyxia, and blood absorption in lungs. This case insists on the deadly potential of this weapon if misused. Fortunately, the term "non-lethal" has been progressively replaced, but sometimes still can be seen, especially in gunsmith and webstores. It should be deleted to avoid confusion among inexperienced people, and at best, this weapon should be restricted to certain professions.

Death, injury and disability from kinetic impact projectiles in crowd-control settings: a systematic review

OBJECTIVE

We conducted a systematic review of the available literature on deaths, injuries and permanent disability from rubber and plastic bullets, as well as from bean bag rounds, shot pellets and other projectiles used in arrests, protests and other contexts from 1 January 1990 until 1 June 2017.

DATA SOURCES

PubMed, Scopus, JSTOR and grey literature.

DATA SYNTHESIS

We report on descriptive statistics as well as data on injury severity, permanent disability and death. We analysed potential risk factors for injury severity, including the site of impact, firing distance and access to medical care.

RESULTS

Of 3228 identified articles, 26 articles met inclusion criteria. These articles included injury data on 1984 people, 53 of whom died as a result of their injuries. 300 people suffered permanent disability. Deaths and permanent disability often resulted from strikes to the head and neck (49.1% of deaths and 82.6% of permanent disabilities). Of the 2135 injuries in those who survived their injuries, 71% were severe, injuries to the skin and to the extremities were most frequent. Anatomical site of impact, firing distance and timely access to medical care were correlated with injury severity and risk of disability.

CONCLUSIONS

Kinetic impact projectiles (KIPs), often called rubber or plastic bullets, are used commonly in crowd-control settings. We find that these projectiles have caused significant morbidity and mortality during the past 27 years, much of it from penetrative injuries and head, neck and torso trauma. Given their inherent inaccuracy, potential for misuse and associated health consequences of severe injury, disability and death, KIPs do not appear to be appropriate weapons for use in crowd-control settings. There is an urgent need to establish international guidelines on the use of crowd-control weapons to prevent unnecessary injuries and deaths.

Facial fractures caused by less-lethal rubber bullet weapons: case series report and literature review

PURPOSE

The present study aims to describe three cases of patients inflicted by rubber bullets with severe facial fractures.

METHODS

In addition, a review of English-language literature involving facial fractures by rubber bullets from 1975 to 2016 was performed.

RESULTS

This current study demonstrated that the use of the LLRBW is unsafety even when applied by police enforcements exclusively.

CONCLUSIONS

Management of facial fractures caused by LLRBW is done in a usual manner with closed or open reduction associated with bone mini-plates or reconstruction plates when indicated. Special initial wound care should be done to avoid secondary infection and additional procedures.

[The possibilities for determining the shooting distance by means of inductively coupled plasma optical emission spectrometry]

The objective of the present study was to evaluate the possibilities for determining the shooting distance for the MR-79-9 Makarych non-lethal pistol (diameter 9 mm, rubber bullet, shot energy 50 J) by means of inductively coupled plasma optical emission spectrometry. The experiments were carried under the conditions of a ballistic shooting range making the shots from a distance of 0 to 120 cm. The 15×15 cm pieces of muslin fabric and biomaterials (leather) were used as the targets. The morphological signs of the damages inflicted to the targets were evaluated either with the unassisted eye, a criminalistical magnifying glass or the SMT-4 binocular stereoscopic microscope (Germany). The shot products, the area and boundaries of their dispersion were determined in reflected IR and filtered UV rays. Inductively coupled plasma optical emission spectrometry was applied for the qualitative and quantitative analysis of various shot products from the entry hole zone with the contamination (wipedown) bands and contusion collars being 0.2-0.5 cm (group 1) and 2-3 cm (group 2) in width, with special reference to the identification of Ba, Cu, Cr, Fe, K, Ni, Pb, Sb, Sn and Zn. The results of the study give evidence that the detection of Ba, Pb, and Sb among the products of a shot fired from the MR-79-9 Makarych non-lethal pistol is of especially high informative value for determining the shooting distance whereas the detection of Cr, K, Sn and Ni is of a minimum value for this purpose.

Head injury assessment of non-lethal projectile impacts: A combined experimental/computational method

The main objective of this study is to develop a methodology to assess this risk based on experimental tests versus numerical predictive head injury simulations. A total of 16 non-lethal projectiles (NLP) impacts were conducted with rigid force plate at three different ranges of impact velocity (120, 72 and 55m/s) and the force/deformation-time data were used for the validation of finite element (FE) NLP. A good accordance between experimental and simulation data were obtained during validation of FE NLP with high correlation value (>0.98) and peak force discrepancy of less than 3%. A state-of-the art finite element head model with enhanced brain and skull material laws and specific head injury criteria was used for numerical computation of NLP impacts. Frontal and lateral FE NLP impacts to the head model at different velocities were performed under LS-DYNA. It is the very first time that the lethality of NLP is assessed by axonal strain computation to predict diffuse axonal injury (DAI) in NLP impacts to head. In case of temporo-parietal impact the min-max risk of DAI is 0-86%. With a velocity above 99.2m/s there is greater than 50% risk of DAI for temporo-parietal impacts. All the medium- and high-velocity impacts are susceptible to skull fracture, with a percentage risk higher than 90%. This study provides tool for a realistic injury (DAI and skull fracture) assessment during NLP impacts to the human head.

Severe craniocerebral trauma with sequelae caused by Flash-Ball® shot, a less-lethal weapon: Report of one case and review of the literature

The use of Flash-Ball® as a non-lethal weapon by several special units within the police and police forces started in France in 1995. Little literature is available concerning injuries caused by Flash-Ball® shooting. However, we report the case of a healthy 34-year-old male victim of a Flash-Ball® shooting during a riot following a sports event. This young man presented serious craniocerebral injuries with a left temporal fracture, moderate cerebral oedema, fronto-temporal haemorrhagic contusion along with an extra-dural hematoma and subarachnoid hemorrhage requiring neurological and rehabilitation care for two months leaving important sequelae. Although the risk is obviously lower than with firearms, Flash-Ball® is nonetheless potentially lethal and may cause serious physical injuries, particularly after a shot to the head.

Medical care in civil disorder

Civil disorder may be defined in widely differing terms, depending largely on the political and legal system prevailing in a given country. The way in which the authorities manage disorder has important implications for both internal stability and the country’s international image, and to a great extent the number of injuries will also depend on the effectiveness of this management.

For the police, ambulance service and hospitals, civil disorder will often necessitate the invocation of their respective major incident plans. Since the response requirements may be very different from other disasters, such plans need to address civil disorder specifically.

This paper reviews the various wounding agents that may be used by participants in civil disorder, and by security forces in their response. The issues of personal safety for emergency service staff are reviewed, and the organizational aspects of medical care emphasized.

Pattern of rubber bullet injuries in the lower limbs: A report from Kashmir

PURPOSE

Rubber bullets are considered a non-lethal method of crowd control and are being used over the world. However the literature regarding the pattern and management of these injuries is scarce for the forensic pathologist as well as for the traumatologist. The objective of this report was to add our experience to the existing literature.

METHODS

From June 2008 to August 2010 the Government Hospital for Bone and Joint Surgery Barzulla and the Department of Orthopaedics, SKIMS Medical College/Hospital Bemina Srinagar received 28 patients for management of their orthopaedic injuries caused by rubber bullets. We documented all injuries and also recorded the management issues and complications that we encountered.

RESULTS

All patients weremales with an age range of 11e32 years and were civilians who had been hit by rubber bullets fired by the police and the paramilitary forces. Among them, 19 patients had injuries of the lower limbs and 9 patients had injuries of the upper limbs. All patients were received within 6 h of being shot.

CONCLUSION

Our findings suggest that these weapons are capable of causing significant injuries including fractures and it is important for the surgeon to be well versed with the management of such injuries especially in areas of unrest. The report is also supportive of the opinion that these weapons are lethal and should hence be reclassified.

Risks of non-lethal weapon use: case studies of three French victims of stinger grenades

The development of non-lethal weapons started in the 1960s. In France, they have been used by the police for about 10 years. We relate the cases of three French women, victims of stinger grenades, non-lethal weapons recently adopted by the French law enforcement to distract and disperse crowds. The three victims presented serious injuries requiring emergency surgical care. One lost her eye. Based on these cases, we discuss the lethal character of these weapons and propose measures to be taken to prevent their dramatic consequences. Although the danger is obviously less than for firearms, stinger grenades are nonetheless potentially lethal and cause serious physical injuries.

Less-lethal hybrid ammunition wounds: a forensic assessment introducing bullet-skin-bone entity

Agencies all around the world now use less-lethal weapons with homogeneous missiles such as bean bag or rubber bullets. Contusions and sometimes significant morbidity have been reported. This study focuses on wounds caused by hybrid ammunition with the pathologists' flap-by-flap procedure. Twenty-four postmortem human subjects were used, and lesions caused on frontal, temporal, sternal, and left tibial regions by a 40-mm hybrid ammunition (33 g weight) were evaluated on various distance range. The 50% risk of fractures occurred at 79.2 m/sec on the forehead, 72.9 m/sec on the temporal, 72.5 m/sec on the sternum, and 76.7 m/sec on the tibia. Skin lesions were not predictors of bone fracture. There was no correlation between soft and bone tissue observed lesions and impact velocity (correlated to distance range). Lesions observed with hybrid ammunition were the result of bullet-skin-bone entity as the interaction of the projectile on skin and bone tissues.

Severe facial rubber bullet injuries: less lethal but extremely harmful weapons

Less-lethal rubber-bullet weapons are designed to induce blunt injuries that incapacitate violent individuals.

AIM AND SCOPE

We intend to study the functional and aesthetic impairments and the cost in terms of social health resulting from rubber-bullet facial trauma.

MATERIALS AND METHODS

We retrospectively collected all the facial trauma cases caused by mass-appeal, less-lethal guns followed up in two French university hospitals since the year 2000. We did not consider the facial injuries caused by professional, less-lethal, rubber or plastic bullet guns.

CONCLUSION

We showed that mass-appeal, less-lethal rubber-bullet guns induce severe traumas with irreversible functional consequences and long-term social implications. Victims of facial rubber-bullet traumas should be managed like high-energy trauma patients and benefit from extremely careful primary wound care.

Rubber bullet injury: case report with autopsy observation and literature review

Rubber bullets are one of the less-lethal (nonlethal) weapons, which are increasingly used to incapacitate dangerous individuals, avoiding use of firearms. An autopsy examination of a man who was shot with improved rubber bullets revealed that the bullet caused pulmonary contusion. The bullet was 30 g in weight and consisted of a sponge foam nose with 40-mm diameter and a plastic body. He was not incapacitated and died of suicidal gunshot wound. The case raised a question as to how severe an injury is necessary to deter a person without causing death. A variety of rubber bullets have been used in the world, and they have occasionally produced severe or lethal injuries. A review of the literature demonstrated that the feature of injuries appeared to be related to the type of missile. It becomes more important for a forensic pathologist to be familiar with rubber bullets and injuries caused by them as the use of less-lethal weapon increases.

Penetrating injury to the chest by an attenuated energy projectile: a case report and literature review of thoracic injuries caused by "less-lethal" munitions

We present the case of a patient who sustained a penetrating injury to the chest caused by an attenuated energy rubber bullet and review the literature on thoracic injuries caused by plastic and rubber "less-lethal" munitions. The patient of this report underwent a right thoracotomy to extract the projectile as well as a wedge resection of the injured lung parenchyma. This case demonstrates that even supposedly safe riot control munition fired at close range, at the torso, can provoke serious injury. Therefore a thorough investigation and close clinical supervision are justified.

Injury pattern of the Flash-Ball, a less-lethal weapon used for law enforcement: report of two cases and review of the literature

Less-lethal weapons are used in law enforcement to neutralize combative individuals and to disperse riot crowds. Local police recently used such an impact weapon, the Flash-Ball, in two different situations. This gun fires large rubber bullets with kinetic energies around 200 J. Although it is designed to avoid skin penetration, impacts at such energies may still create major trauma with associated severe injuries to internal organs. This is a report of 2 patients shot with the Flash-Ball who required medical attention. One could be discharged quickly, but the other required hospitalization for heart and lung contusion. Both patients required advanced investigations including computed tomography (CT) scan. The medical literature on injuries induced by less-lethal impact weapons is reviewed. Impacts from the Flash-Ball can cause significant injury to internal organs, even without penetration. Investigations as for other high-energy blunt traumas are called for in these cases.

Ocular rubber bullet injuries

PURPOSE

To report the type and severity of ocular and orbital injuries caused by rubber bullets.

METHODS

A total of 42 consecutive patients seen over a 3-month period with ocular and orbital rubber bullet injuries were assessed clinically and radiographically within 1 day of injury, and the findings were recorded. Clinical outcomes following treatment were also recorded up to 6 months postinjury.

RESULTS

A total of 90% of the patients were male. The mean age of patients was 25.0 years (4-60). Of the patients, 54% had lid or skin lacerations, 40% hyphaema, 38% ruptured globe, 33% orbital fracture, 26% retinal damage, and 21% retained rubber bullet in or around the orbit. At follow-up, 53% of the patients had a visual acuity of less than 6/60, 7% less than 6/18 to 6/60, and 40% 6/18 or better.

CONCLUSIONS

The term 'rubber bullet' is misleading. 'Rubber bullets' cause a wide variety of ocular and periocular injuries. Orbital fractures are common. The tissues of the orbit are easily penetrated. If the globe is hit, it is rarely salvageable.

Injury patterns related to use of less-lethal weapons during a period of civil unrest

This case series documents injury patterns related to beanbag and other less-lethal (LL) weapons during a period of civil unrest in a major U.S. city. A retrospective review of injuries related to LL weapons usage presenting to an urban Emergency Department (ED) from April 10, 2001 to April 18, 2001 was performed. Patients under 18 years of age and those without signed consent to treat were excluded. Twenty-seven patients were identified. Two were excluded due to lack of signed consent for treatment. Mean age was 28.4 +/- 11.7 years; 76% of patients were male. Significant morbidity was found in 7 (28%) cases with no fatalities. Three (12%) individuals, with the diagnoses of pulmonary contusion, liver laceration, and Achilles tendon rupture, required admission. Two (8%) individuals had delayed complications of pneumonia and post-concussive syndrome. Reports of injury patterns associated with beanbag munitions in the medical literature are limited. Physicians should be aware of the injuries and delayed sequelae associated with their use.

Blunt and penetrating injuries caused by rubber bullets during the Israeli-Arab conflict in October, 2000: a retrospective study

BACKGROUND

Low-velocity rubber bullets were used by Israeli police to control riots by Israeli-Arabs in early October, 2000. We aimed to establish the factors that contribute to severity of blunt and penetrating injuries caused by these missiles.

METHODS

We analysed medical records of 595 casualties admitted. We assessed relation of severity of injury to type of bullet, anatomical region of injury, and final outcome. Severity of injury was established by the abbreviated injury scale, and we calculated injury severity score.

FINDINGS

151 males and one female (age range 11-59 years) were included in the study, in whom 201 proven injuries by rubber bullets were detected. Injuries were distributed randomly over the body surface and were mostly located in the limbs (n=73), but those to the head, neck, and face (61), chest (39), back (16), and abdomen (12) were also frequently noted. 93 (61%) patients had blunt injuries and 59 (39%) penetrating ones. Severity of injury was dependent on ballistic features of the bullet, firing range, and anatomic site of impact. Two casualties died after a penetrating ocular injury into the brain and one died as a result of postoperative aspiration after a knee injury.

INTERPRETATION

Resistance of the body surface at the site of impact (elastic limit) is the important factor that ascertains whether a blunt or penetrating injury is inflicted and its severity. Inaccuracy of rubber bullets and improper aiming and range of use resulted in severe injury and death in a substantial number of people. This ammunition should therefore not be considered a safe method of crowd control.

Baton rounds

Baton rounds are the final step in a graded response to civil disturbance and have recently been adopted for use on the British mainland. Designed to be a less lethal weapon, they are still responsible for serious injuries and deaths. A review of the literature is presented covering the ballistics, demographics, and injuries resulting from the use of baton rounds and offering some specific management guidelines. The recent developments in baton round design and guidelines for use are described and the problems of terminology with plastic bullets are examined.

The role of sub-lethal weapons in human rights abuse

This article is based on two recent reports contracted by the European Parliament (EP), which assessed sub-lethal weapons as flexible tools of political control. It analyses the role and function of existing weapons systems in human rights abuses using examples from Indonesia, Israel, Kenya, Northern Ireland and Turkey. These weapons are designed to 'appear' rather than 'be' safe and, since they augment rather than replace lethal technologies, their use can distort conflicts and actually bridge the firewall between use of less-lethal and lethal technologies.

Plastic bullet injuries in Northern Ireland: experiences during a week of civil disturbance

BACKGROUND

Plastic bullets were introduced to Northern Ireland for riot-control purposes in 1973. Their use has been controversial, with a number of fatalities. In the week beginning July 7, 1996, some 8,000 plastic bullets were fired during widespread rioting.

METHODS

Details of injuries attributed to plastic bullets were obtained retrospectively from patient notes for the period July 8 to 14, 1996, in six hospitals. A total of 172 injuries in 155 patients were recorded.

RESULTS

Nineteen percent of injuries were to the face/head/neck, 20% were to the chest or abdomen, and 61% were to the limbs. Abbreviated Injury Scale scores ranged from I to 3. Forty-two patients were admitted for hospitalization, three to intensive care units. No fatalities occurred.

CONCLUSION

Plastic bullet impact to the abdomen or above may cause life-threatening injuries. Below this site, major trauma is unlikely.

Injury patterns in a plastic (AR-1) baton fatality

Rubber and plastic bullets or batons have been used in countries outside the United States for several years. These devices were designed to inflict nonlethal force in riot control. The authors report a case of fatal injury sustained by an elderly woman struck in the chest by a plastic baton, including the circumstances surrounding this unusual incident, the autopsy findings and a review of the literature.

Victims of the Palestinian uprising (Intifada): a retrospective review of 220 cases

The purpose of this study was to review the cases of the victims of the Palestinian uprising (Intifada) and to describe the clinical presentations, the types of weapons used, and the different sites of injuries. This is a retrospective chart review study of the patients who were injured during the Palestinian uprising in the period April 1993-April 1994 and treated in the emergency department of the Barzilai Medical Center, Ashkelon, Israel. The Barzilai Medical Center is a regional level II trauma referral general hospital. Two hundred and twenty patients were injured during the Palestinian uprising and referred to our emergency department. Forty-one patients were citizens of the Gaza area, 26 patients were Israeli civilians, and 153 were Israeli soldiers. There were 55 patients (25%) injured by firearms, 10 patients (4.5%) by explosives, and 120 (54.5%) by striking stones. Seventy-three patients (33.2%) were hospitalized, and 22 patients needed surgery. The most commonly injured part of the body was the lower limb among the Gaza citizens and the head and neck among the Israeli soldiers and civilians. Striking stones was the most common means of injury used by the Palestinians, and stab wounds by knives and other sharp objects were the most common injuries among Israeli civilians. None of the patients suffered direct blast injuries. The Palestinian uprising resulted in many victims and disabled people in both nations. Terrorism did not cease after the peace treaty. It changed its face and moved from Gaza to the center of Israel. Suicidal terrorist bombing in public spaces and public buses carries more danger and more victims with much more severe injuries. We hope that the future will be brighter, and both nations will eventually be able to live in peace.

Rubber and plastic ammunition lethal injuries: the Israeli experience

Rubber and plastic ammunition was used by the Israeli Defence Forces between the years 1987 and 1993 (Intifada) almost exclusively as a deterrent to aggression by the Palestinian civilian population in the occupied territories of Gaza, Judea and Samaria. While designed to avoid the serious wounds and deaths caused by the use of conventional military ammunition, the firing of rubber and plastic bullets has resulted in extensive injuries and more than 20 deaths. The data from the autopsies of 17 of these victims, mostly teenagers, were analysed. Ten of the victims died from injuries inflicted by Improved Rubber Bullets, while the other seven succumbed to injuries caused by Plastic Bullets. In most instances, the cause of death was related to injuries to the brain. Ballistic features of non-conventional bullets are discussed, and suggestions to curtail the serious injuries and fatalities arising from their use are given, with emphasis on firing from a safe range. British and South African experience with this type of ammunition is compared with our observations.

Pediatric craniocerebral wounds from plastic bullets: prognostic implications, course, and outcome

OBJECTIVE

To review our experience with craniocerebral injuries caused by plastic bullets, and to delineate prognostic factors for outcome.

DESIGN

Retrospective case series of 29 patients presenting with plastic bullet-induced craniocerebral lesions.

SETTING

Pediatric intensive care department of a tertiary care center.

MEASUREMENTS AND MAIN RESULTS

Outcome was poor in 10 patients, good in 11, and two and six patients were moderately and severely disabled, respectively. Statistical analysis showed prognostic significance of the admission Glasgow Coma Scale score, computed tomographic findings of intraventricular hemorrhage and midline shift, and metabolic studies including hypokalemia and hyperglycemia.

CONCLUSIONS

Plastic bullet-induced craniocerebral injuries carry a lower morbidity and mortality rate compared with other gunshot wounds. However, plastic bullets do incur a significant risk of injury. Their use should be carefully regulated.

The fatalities of the Intifada (uprising): the first five years

The uprising of the Palestinian population (Intifada) against the Israeli occupation of the Gaza Strip and the West Bank, which erupted in December 1987, has resulted in the deaths of hundreds of Israeli citizens and Palestinian residents. The data on dead victims, as reported by two civil rights organizations of opposite political orientation and by the official military authority, are analyzed and compared with the information obtained from post-mortem examinations of some 65% of the victims carried out over the period 1987 to 1992. The agencies' reports were found to differ, sometimes markedly, from the official autopsy data in respect of number of deaths, their cause and manner. The study indicates a generally downward trend in the number of Palestinians killed by the Israeli Defence Forces, which could be the result of the wider use of rubber and plastic bullets, and a steady continuous increase in Israeli victims killed by the Palestinians, possibly accounted for by a shift from the use of "cold weapons" in favour of firearms, and an escalation in violence. It is suggested that the post-mortem examination should be an essential tool for the detection and documentation of possible abuse and bodily harm.

The anatomy of plastic bullet damage and crowd control

The plastic bullet was introduced into Northern Ireland as a riot control weapon in 1973. It became fully operational in 1975, replacing its predecessor the rubber bullet. The missile, which has been portrayed as a "minimum force," nonlethal weapon, has resulted in 13 deaths, including those of seven children, and scores of serious, permanent injuries and disabilities. Evidence regarding injury inflicted by the plastic bullet indicates that it is more dangerous than the rubber bullet that it replaced. It tends to cause more serious injuries to the skull and brain and therefore more deaths. An examination of the three rubber bullet and 13 plastic bullet deaths reveals that most victims were shot from distances much less than that determined to be "safe" and in a manner that contrasted with the rules of engagement. The data from numerous case studies seem to support allegations of abuse of the weapon by security forces.

Injuries caused by plastic bullets compared with those caused by rubber bullets

The injuries sustained by 99 people struck by plastic bullets, were compared with those sustained by 90 people struck by rubber bullets. Plastic bullets struck the head and chest less often than rubber bullets and caused fewer serious injuries to the face and chest, but tended to cause more serious skull and brain injuries.

Some missile injuries due to civil unrest in Northern Ireland

Some missile injuries are reviewed after nearly 8 years of continuous warfare. A feature of many of these injuries is the early admission to hospital which has had a profound effect on the survival rate and the recovery period. Some examples are given of injuries inflicted by rubber bullets. The effects of wounding by low and high velocity missiles are described and examples given. An injury caused by a missile incorporated in a bomb is also shown.

Plastic bullet injury: a case report

Plastic bullets have been introduced into Northern Ireland for use by the Security Forces in riot control. They are alleged to be more accurate in flight than the rubber bullet and are cheaper to produce. The injuries to a patient caused by a plastic bullet are described.