Br. J. Surg. Vol. 62 (1975) 480486
Injuries caused by rubber bullets: a report on 90 patients R. M I L L A R , W. H. R U T H E R F O R D , S. J O H N S T O N A N D V. J. M A L H O T R A * SUMMARY
The injuries in 90 patients caused by rubber bullets are described. There was I death and I 7 people in the series had permanent disabilities or deformities. In 41 patients the injuries necessitated admission to hospital. One fatality outside this series is known. Injuries to the head and neck were frequent and severe.
IN July 1970 in Northern Ireland the British Army introduced a new missile, the rubber bullet. This article describes the injuries to 90 patients caused by this missile. Cases were collected by contacting all the hospitals in Belfast and Londonderry and asking for details about rubber bullet injuries. Most of the serious and many of the minor injuries were seen personally by one or more of the authors. Ballistic details The rubber bullet is a blunt missile which is intended to administer a painful slap severe enough to deter stone throwers but not severe enough to cause major injuries. It is the mechanical descendant of the wooden club or baton. The first attempt to modify a baton so that it could be fired was in Hong Kong. This missile was made of wood, and the Army spoke of ‘firing baton rounds’. For the civil disturbances in Northern Ireland the wooden missile was replaced by one made of hard rubber. The Army has continued to speak of ‘firing baton rounds’, but civilians have always referred to the missiles as ‘rubber bullets’.
When the rubber bullet was designed it was decided to use it for firing in a weapon already in production. The weapon chosen was designed originally for firing canisters of CS gas, and is in current use by the Royal Ulster Constabulary for this purpose. The army refers to this weapon as the ‘RUC riot gun’. A rubber buffet can also be fired from the Verey pistol. The term ‘bullet’ gives a correct impression of shape, but not of size-it is 15 crn long, 3.5 cm in diameter and weighs 135-140 g. It is mounted in a canister with a charge of 55 grains in the base (Fig. 1). It fits loosely into the barrel of the riot gun and is highly unstable in flight. The muzzle velocity is 73 mlsec, but with tumbling movement and high wind resistance it loses energy very rapidly. The loose barrel and tumbling flight are also responsible for its inaccuracy. At 18 m it is difficult to hit a target 2 m in diameter. Patients Table I shows the sex distribution. It is noteworthy that while women formed 33 per cent of the total series, they represented only 10 per cent of the patients who required admission to hospital. Of the less serious cases where admission was not necessary, just over 50 per cent were women. Table II shows the age distribution. The youngest patient was 7 years old and the oldest 67. Table 111 shows the anatomical site of the injuries. In 5 cases two areas of the body were injured, giving 95 sites in 90 patients. The great majority of these lesions were on the anterior aspect, a few were lateral and only two were on the posterior aspect, one on the back of the neck and the other on the back of a leg. Injuries to specific organs 1. Skin and soft tissues Of the 90 patients, the records note the absence of obvious damage to the skin and soft tissues in only 2 or 3 cases. By far the most common lesion was a bruise, and this was usually elongated, in some cases giving a striking reproduction of the shape of the bullet (Figs. 2, 3, 4). In 2 cases it was noted that the bruise was circular, presumably from an end-on impact. The typical shape of the bruise was somewhat less evident in face and head injuries. Injuries to the face characteristically caused gross swelling and bruising of the cheek, lips and eyelids, with or without abrasions and lacerations (Figs. 5, 6). There was one scalp laceration with no skull fracture, but in one case of very severe comminuted skull fracture there was no overlying laceration.
Fig. 1. Rubber bullet with its cannister.
480
* Royal Victoria Hospital, Belfast.
Injuries caused by rubber bullets Table I: SEX DISTRIBUTION Outpatients Inpatients Sex Men Women Total
No.
Y
24 25
49 51
49
100
Totdl
Y
No.
9/,
37 4
90 10
61 29
61 33
41
100
90
100
No.
Table 11: AGE DISTRIBUTION Total Age (yr)
Outpatients
Inpatients
No.
%
2 30 9 7 1
3 28 2 7 1
5 58
2
6 64 12 16 2
49
41
90
100
~~
0-9 10-19 20-39 40
+
Unknown Total
11 14
Table 111: SITE OF INJURY Site
Outpatients
Head and neck Chest Abdomen Arms Legs
18 14 3
Total
Inpatients No. % 33 7
11
1 0 0
54
41
8
80 18 2 0
20
Fig. 2. Typical longitudinal bruise on the abdomen.
% 54 22 4
0
51 21 4 8 11
100
95
100
Table 1V: FACE AND SKULL FRACTURES Site Disolaced Undisolaced Malar 5 7 Maxilla 2 0 Orbital floor 5 0 Nose 4 7 Mandible 1 1 Skull 3 0 Total
Total No.
15
8
12
Total 12 2 5 11
2 3 35
In one case a bruise on the calf of the leg later broke down with considerable sloughing of the subcutaneous tissues. This was skin-grafted and healed well. One bruise over the lower chest wall and epigastrium increased in size and on the fifth day measured 30cm and was fluctuant; 150ml of thin, bloodstained fluid, full of fat globules, were removed, presumably the result of traumatic fat necrosis. 2. Bony injuries The only fracture in a long bone of the limbs was in a finger (a dislocation of a proximal interphalangeal joint with fracture of the base of the middle phalanx) (Fig. 7 ) . In this case the finger was pinched between the rubber bullet and a wall. In the trunk the only fractures were of the ribs. Of 24 chest injuries, 9 of which required admission, rib fractures occurred in only 2 cases. By contrast, fractures of the face and skull were relatively common. There were no fractures among 18 injuries to the head where admission was judged unnecessary. Of 33 patients with head injuries who were admitted, 21 patients had sustained fractures of the face and skull bones. Several patients had fractures at more than one site, making a total of 35 fractures. Table I V sets out the details of these fractures.
Fig. 3. Circular bruise over right lower ribs.
Fig. 4. Bruising with imprint of rubber bullet.
Fractures of the facial bones and skull did not show any unusual features as compared with those due to other types of blunt trauma. The fracture patterns reflect the direction and momentum of the missiles and the inherent lines of weakness in the skeleton of the face. In most cases the impact was from the side and a 48 1
R. Millar et al. common injury was a fracture of the malar and/or nasal bones. Blow-out fracture of the orbit also occurred. In one case the force was sufficient to displace the maxilla laterally and in another the mandible was fractured and displaced. One patient had a depressed fracture in the frontotemporal region combined with massive shattering of the whole vault of the skull (Fig. 8). Fractures due to frontal impact were less common. In several cases the nasal bones were comminuted and flattened. In one of these there was an associated fracture of the frontal bones with a cerebrospinal fluid leak for several days. In another the whole maxilla was driven downwards and backwards and there were associated fractures of the malar bones and nose and a blow-out fracture of the left orbit (Figs. 6, 9). In this patient both eyes were ruptured. Another patient, who suffers from osteogenesis imperfecta, had a direct impact on the frontal bones, resulting in a depressed fracture and an extradural haematoma which required surgical intervention. Fig. 5. Typical face injury with gross swelling of the orbit and undisplaced malar fracture.
3. Eyes and ocular adnexa Twenty-four cases had injuries to the eyes or adnexa, 4 of which were bilateral; 10 right eyes and 18 left were involved (Table V ) . Two (8 per cent) of the patients were women. This is similar to the percentage of women among inpatients (10 per cent) rather than in the total series (33 per cent). In comparison with injuries to other sites of the body there was a similar age range but more cases occurred in the older age groups. All except 4 were treated as inpatients, with an average duration of 10 days’ hospitalization. Gross ecchymosis, periorbital and orbital oedema were a feature of all the cases (Fig. 5). In 7 cases bruising and lacerations of the lids alone were involved and these all had good visual results and no permanent disability. Thirteen cases had associated facial or skull fractures of which 6 reauired surgical reduction. Twenty globes were injured, contusion accounting for 12. Severe visual loss was caused by traumatic cataract in 2 and by choroidal tears and retinal scarring in the macular region in 6. There were 8 ruptured globes all of which resulted in blindness; 4 had to be excised. A bilateral case who was severely injured at short range is shown in Fig. 6. Apart from visual loss, permanent disability was caused by anosmia in 3 cases and a marked change of facial appearance in 3 cases.
-
Fig. 6. Severe injury with compound fracture of the nose,
maxillary fracture and destruction of both eyes.
4. Brain
Fig. 7. Fracture of the base of the middle phalanx of the right ring finger.
482
In 7 patients there was loss of consciousness. In 2 this was very brief-a matter of a few minutes-and in another 2 there was amnesia for less than 1 hour. Of these 4 mild cases, one was associated with a fractured mandible and the other 3 had no bony injuries. The 3 more severe cases of brain injury were associated with skull fractures. One of these made a complete recovery with no disability, one recovered well in spite of the damage to a frontal lobe noted at operation and the third patient died (Fig. 8). At operation he was noted to have gross cerebral oedema. It is noteworthy that no unconsciousness or amnesia was noted in any of the
Injuries caused by rubber bullets
a Table V: EYE INJURIES
Injury Contusion and laceration of lids Contusion of globe Ruptured globe Total
Visual results Poor Good (6/36Blind (>6/12) 3/60) (
Injuries caused by rubber bullets: a report on 90 patients R. M I L L A R , W. H. R U T H E R F O R D , S. J O H N S T O N A N D V. J. M A L H O T R A * SUMMARY
The injuries in 90 patients caused by rubber bullets are described. There was I death and I 7 people in the series had permanent disabilities or deformities. In 41 patients the injuries necessitated admission to hospital. One fatality outside this series is known. Injuries to the head and neck were frequent and severe.
IN July 1970 in Northern Ireland the British Army introduced a new missile, the rubber bullet. This article describes the injuries to 90 patients caused by this missile. Cases were collected by contacting all the hospitals in Belfast and Londonderry and asking for details about rubber bullet injuries. Most of the serious and many of the minor injuries were seen personally by one or more of the authors. Ballistic details The rubber bullet is a blunt missile which is intended to administer a painful slap severe enough to deter stone throwers but not severe enough to cause major injuries. It is the mechanical descendant of the wooden club or baton. The first attempt to modify a baton so that it could be fired was in Hong Kong. This missile was made of wood, and the Army spoke of ‘firing baton rounds’. For the civil disturbances in Northern Ireland the wooden missile was replaced by one made of hard rubber. The Army has continued to speak of ‘firing baton rounds’, but civilians have always referred to the missiles as ‘rubber bullets’.
When the rubber bullet was designed it was decided to use it for firing in a weapon already in production. The weapon chosen was designed originally for firing canisters of CS gas, and is in current use by the Royal Ulster Constabulary for this purpose. The army refers to this weapon as the ‘RUC riot gun’. A rubber buffet can also be fired from the Verey pistol. The term ‘bullet’ gives a correct impression of shape, but not of size-it is 15 crn long, 3.5 cm in diameter and weighs 135-140 g. It is mounted in a canister with a charge of 55 grains in the base (Fig. 1). It fits loosely into the barrel of the riot gun and is highly unstable in flight. The muzzle velocity is 73 mlsec, but with tumbling movement and high wind resistance it loses energy very rapidly. The loose barrel and tumbling flight are also responsible for its inaccuracy. At 18 m it is difficult to hit a target 2 m in diameter. Patients Table I shows the sex distribution. It is noteworthy that while women formed 33 per cent of the total series, they represented only 10 per cent of the patients who required admission to hospital. Of the less serious cases where admission was not necessary, just over 50 per cent were women. Table II shows the age distribution. The youngest patient was 7 years old and the oldest 67. Table 111 shows the anatomical site of the injuries. In 5 cases two areas of the body were injured, giving 95 sites in 90 patients. The great majority of these lesions were on the anterior aspect, a few were lateral and only two were on the posterior aspect, one on the back of the neck and the other on the back of a leg. Injuries to specific organs 1. Skin and soft tissues Of the 90 patients, the records note the absence of obvious damage to the skin and soft tissues in only 2 or 3 cases. By far the most common lesion was a bruise, and this was usually elongated, in some cases giving a striking reproduction of the shape of the bullet (Figs. 2, 3, 4). In 2 cases it was noted that the bruise was circular, presumably from an end-on impact. The typical shape of the bruise was somewhat less evident in face and head injuries. Injuries to the face characteristically caused gross swelling and bruising of the cheek, lips and eyelids, with or without abrasions and lacerations (Figs. 5, 6). There was one scalp laceration with no skull fracture, but in one case of very severe comminuted skull fracture there was no overlying laceration.
Fig. 1. Rubber bullet with its cannister.
480
* Royal Victoria Hospital, Belfast.
Injuries caused by rubber bullets Table I: SEX DISTRIBUTION Outpatients Inpatients Sex Men Women Total
No.
Y
24 25
49 51
49
100
Totdl
Y
No.
9/,
37 4
90 10
61 29
61 33
41
100
90
100
No.
Table 11: AGE DISTRIBUTION Total Age (yr)
Outpatients
Inpatients
No.
%
2 30 9 7 1
3 28 2 7 1
5 58
2
6 64 12 16 2
49
41
90
100
~~
0-9 10-19 20-39 40
+
Unknown Total
11 14
Table 111: SITE OF INJURY Site
Outpatients
Head and neck Chest Abdomen Arms Legs
18 14 3
Total
Inpatients No. % 33 7
11
1 0 0
54
41
8
80 18 2 0
20
Fig. 2. Typical longitudinal bruise on the abdomen.
% 54 22 4
0
51 21 4 8 11
100
95
100
Table 1V: FACE AND SKULL FRACTURES Site Disolaced Undisolaced Malar 5 7 Maxilla 2 0 Orbital floor 5 0 Nose 4 7 Mandible 1 1 Skull 3 0 Total
Total No.
15
8
12
Total 12 2 5 11
2 3 35
In one case a bruise on the calf of the leg later broke down with considerable sloughing of the subcutaneous tissues. This was skin-grafted and healed well. One bruise over the lower chest wall and epigastrium increased in size and on the fifth day measured 30cm and was fluctuant; 150ml of thin, bloodstained fluid, full of fat globules, were removed, presumably the result of traumatic fat necrosis. 2. Bony injuries The only fracture in a long bone of the limbs was in a finger (a dislocation of a proximal interphalangeal joint with fracture of the base of the middle phalanx) (Fig. 7 ) . In this case the finger was pinched between the rubber bullet and a wall. In the trunk the only fractures were of the ribs. Of 24 chest injuries, 9 of which required admission, rib fractures occurred in only 2 cases. By contrast, fractures of the face and skull were relatively common. There were no fractures among 18 injuries to the head where admission was judged unnecessary. Of 33 patients with head injuries who were admitted, 21 patients had sustained fractures of the face and skull bones. Several patients had fractures at more than one site, making a total of 35 fractures. Table I V sets out the details of these fractures.
Fig. 3. Circular bruise over right lower ribs.
Fig. 4. Bruising with imprint of rubber bullet.
Fractures of the facial bones and skull did not show any unusual features as compared with those due to other types of blunt trauma. The fracture patterns reflect the direction and momentum of the missiles and the inherent lines of weakness in the skeleton of the face. In most cases the impact was from the side and a 48 1
R. Millar et al. common injury was a fracture of the malar and/or nasal bones. Blow-out fracture of the orbit also occurred. In one case the force was sufficient to displace the maxilla laterally and in another the mandible was fractured and displaced. One patient had a depressed fracture in the frontotemporal region combined with massive shattering of the whole vault of the skull (Fig. 8). Fractures due to frontal impact were less common. In several cases the nasal bones were comminuted and flattened. In one of these there was an associated fracture of the frontal bones with a cerebrospinal fluid leak for several days. In another the whole maxilla was driven downwards and backwards and there were associated fractures of the malar bones and nose and a blow-out fracture of the left orbit (Figs. 6, 9). In this patient both eyes were ruptured. Another patient, who suffers from osteogenesis imperfecta, had a direct impact on the frontal bones, resulting in a depressed fracture and an extradural haematoma which required surgical intervention. Fig. 5. Typical face injury with gross swelling of the orbit and undisplaced malar fracture.
3. Eyes and ocular adnexa Twenty-four cases had injuries to the eyes or adnexa, 4 of which were bilateral; 10 right eyes and 18 left were involved (Table V ) . Two (8 per cent) of the patients were women. This is similar to the percentage of women among inpatients (10 per cent) rather than in the total series (33 per cent). In comparison with injuries to other sites of the body there was a similar age range but more cases occurred in the older age groups. All except 4 were treated as inpatients, with an average duration of 10 days’ hospitalization. Gross ecchymosis, periorbital and orbital oedema were a feature of all the cases (Fig. 5). In 7 cases bruising and lacerations of the lids alone were involved and these all had good visual results and no permanent disability. Thirteen cases had associated facial or skull fractures of which 6 reauired surgical reduction. Twenty globes were injured, contusion accounting for 12. Severe visual loss was caused by traumatic cataract in 2 and by choroidal tears and retinal scarring in the macular region in 6. There were 8 ruptured globes all of which resulted in blindness; 4 had to be excised. A bilateral case who was severely injured at short range is shown in Fig. 6. Apart from visual loss, permanent disability was caused by anosmia in 3 cases and a marked change of facial appearance in 3 cases.
-
Fig. 6. Severe injury with compound fracture of the nose,
maxillary fracture and destruction of both eyes.
4. Brain
Fig. 7. Fracture of the base of the middle phalanx of the right ring finger.
482
In 7 patients there was loss of consciousness. In 2 this was very brief-a matter of a few minutes-and in another 2 there was amnesia for less than 1 hour. Of these 4 mild cases, one was associated with a fractured mandible and the other 3 had no bony injuries. The 3 more severe cases of brain injury were associated with skull fractures. One of these made a complete recovery with no disability, one recovered well in spite of the damage to a frontal lobe noted at operation and the third patient died (Fig. 8). At operation he was noted to have gross cerebral oedema. It is noteworthy that no unconsciousness or amnesia was noted in any of the
Injuries caused by rubber bullets
a Table V: EYE INJURIES
Injury Contusion and laceration of lids Contusion of globe Ruptured globe Total
Visual results Poor Good (6/36Blind (>6/12) 3/60) (
