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CONCEPTS, COMPONENTS & CONFIGURATIONS
ballistics; wounds, ballistics

Wound Ballistics: Theory and Practice

Ballistics is the study of the natural laws governing projectile missiles and Gary J Ordog, MD
their predictable performances, and wound ballistics is the study of a mis- Jonathan Wasserberger, MD
sile's effect on living tissue. A knowledge of these topics is essential to deter- Subramanian Balasubramanium, MD
mine the extent and type of injury from a missile. The type of missile can Los Angeles, California
often be determined by radiography. The caliber can be measured directly if
the bullet is close to the x-ray plate and the x-ray tube is at least six feet From the Department of Emergency
Medicine, Charles R Drew/UCLA School of
from the film. Changing these distances can result in a maximum magni- Medicine, Los Angeles, California.
fication of the bullet image of 20%, and the exact amount can be calculated
using a formula provided. Definitions of ballistic and wound ballistic terms
Received for publication April 16, 1984.
are provided, as are examples of wound ballistics in application. [Ordog GJ,
Revision received July 9, 1984.
Wasserberger J, Balasubramanium S: Wound ballistics: Theory and practice. Accepted for publication August 14, 1984.
Ann Emerg Med December 1984;13:1113-1122.]
Address for reprints: Gary Ordog, MD,
INTRODUCTION Box 219-12021 South Wilmington, Los
At least 30,000 deaths and 300,000 missile injuries occur annually in the Angeles, California 90059.
United States, a number similar to American Viet N a m war casualty fig-
uresJ With an increasing incidence and prevalence of missile injuries in cer-
tain areas it is essential that the traumatologist be familiar with wound bal-
listics, 1 which can help the physician determine the extent and type of
injury from a known missile. 2 Ballistics, the study of the natural laws gov-
erning projectile missiles and their predictable performances,3 can be divided
into three phases: interior, actions within the firearm; exterior, from the end
of the muzzle to the target; and terminal, after entering the target. 3 Wound
ballistics relates specifically to the terminal phase of ballistics, as the study
of the missile's effect on living tissue. 3
We discuss wound ballistics and explain how the type and extent of injury
often can be determined to provide better care for the injured patient. Defini-
tions of wound ballistic terms (Figure 1) and a brief history of the study of
wound ballistics {Figure 2) are shown. Presentations of several applications of
ballistics also are shown (Figures 3 to 15).

ENERGY
Two important characteristics of a missile are mass and velocity. Velocity
is far more significant than is mass in regard to wounding capacity. Various
theories and formulas have been derived to determine the wounding capacity
of a missile. The m o m e n t u m theory purports that m o m e n t u m (mass x ve-
locity) is most important in wounding capacity, and this theory has been
used in the design of big-game rifles. The power theory states that power
(mass x velocity 3) is m o s t important. The m o s t widely accepted theory
states that wounding capacity is related to the kinetic energy (mass x ve-
locity2)91
mass x (V12 - V22)
Kinetic energy = 2 x g
where V1 is impact velocity and V2 is exit or remaining velocity. Note that
doubling the mass of the bullet only doubles the kinetic energy, while dou-
bling the velocity quadruples the kinetic energy, representing the rationale
behind m a g n u m or special shells.
Rifling in the gun barrel causes the bullet to spin. This rotational energy
can be transferred to the tissue as well and can be calculated by the following

13:12 December 1984 Annals of Emergency Medicine 1113/67

WOUND BALLISTICS
Ordog, Wasserberger & Balasubramanium
formula:
Rotational = I (W]2-W22)
energy 2
where I is m o m e n t of inertia in feet or
slugs, W1 is angular velocity at impact
in radians per second, and W2 is an-
gular velocity on exit.
Total k i n e t i c energy of a bullet
entry into tissue can be estimated by
adding both the energy due to velocity
and the rotational energy. The impact
velocity, or velocity at which the bul-
let hits the target, is what is figured in
the calculations. For practical pur-
poses, in civilian low-velocity weap-
ons at less than 50 yards and high-
v e l o c i t y w e a p o n s at less t h a n 100
yards, the impact velocity is equal to
the muzzle velocity.
The impact velocity for penetrating
various s t r u c t u r e s has been deter-
mined. An impact velocity of 150 feet/
second is required to penetrate the
skin, and 195 feet/second is required
to break bone. Such vulnerable tissues
as the eye can be d a m a g e d at ve-
locities considerably less than these.
Moreover, death can be caused by vital
organ damage at low velocities if the
appropriate structure is hit.
A m a g n u m shell increases the ener-
gy of the bullet by 20% to 60% by in-
creasing the gun powder charge. This
can increase the muzzle velocity by
366 to 456 feet/second. The energy of
a rifle bullet is m u c h greater than that
of the equivalent-caliber handgun bul-
let, even if that h a n d g u n is loaded
with a m a g n u m or special shell. A
m a g n u m rifle bullet may have up to
12 t i m e s the k i n e t i c energy of its
equivalent standard handgun bullet 3
(Table 1).
MISSILE-RETARDING FACTORS
Factors that tend to retard or slow a
bullet in the target or tissue will de-
crease the kinetic energy of the bullet,
t u r n i n g k i n e t i c e n e r g y i n t o Other
forms such as heat, vibration, me-
chanical and v a c u u m forces, all of
which can damage tissues. These re-
tardants previously have been called
forces, although they are not actually
forces in the physical or engineering
sense.2,12
The m o s t significant factor of the
target tissue in retarding the bullet is
the specific gravity of the tissue 1~
(Table 2). The higher the specific grav-
ity of the tissue, the greater the retar-
dation effect on the bullet and the
more energy imparted into the tissues,
leading to greater destruction of these
68/1114
Ballistic coefficient - - The efficiency of a bullet in overcoming air resistance
depends on bullet shape (ogive), density, and diameter.
Caliber - - Bore diameter in inches (or millimeters); 2 standard calibers range
from 0.17 to 0.46 for rifles and 0.15 to 0.45 for handguns. 3
Casualty criterion - - Kinetic energy of a missile needed to put a soldier out
of combat; Americans define this as 58 foot-pounds and Russians, 174
foot-pounds. 4
Cavitation.-- Cavity created during passage of a bullet through the target by
air being sucked in. 2
Dumdum bullets - - Bullets that are either not jacketed or only partially jack-
eted which expand and flatten on impact, thus increasing energy dis-
sipation and tissue destruction. Also called expanding, mushroom, sport-
ing, or soft-nose bullets. 2
Geneva Convention - - States that all military bullets must be fully jacketed
so as to cause less tissue damage, but be more likely to pass through the
target.
Handgun - - Pistols firing bullets with calibers ranging from .22 to .45, all low
velocity, including the magnums.
High velocity missile - - Above 2,500 feet/second, 1,2 when bullet can cause
both shock waves and cavitation which increase tissue destruction. In-
cludes those bullets from most rifles, but not from handguns. 3
Impact velocity - - Velocity of the bullet as it strikes the target. 2
Jacket - - An outer layer of high-melting-point metal used to cover the lead
of a bullet so that the bullet maintains its original shape.
Magnum s h e l l - Extra gunpowder added to a shell to provide the bullet
with 20% to 60% more energy than a standard shell of the same caliber.
Increased energy is due to increased velocity. 5
Missiles - - Any projectile, including bullets, pellets, grenade fragments, and
explosive shells. 2
Muzzle velocity - - Velocity as bullet leaves the gun's barrel.2
Nutation - - Rotation in small circles forming a rosette pattern.6
Ogive - - Radius of a bullet in lateral projection.
Precession - - Wobbling or circular yawing around the center of mass in a
spiral fashion.2
Retardant forces - - Forces that tend to slow the missile once it enters the
target. Greater retardant forces increase energy transfer to the tissue,
and thus cause greater tissue damage. 2
Rifle - - The bullet from a rifle has much greater energy than the equivalent
handgun. Except for the .22 caliber rifle, most can be considered high-
velocity.
Shotgun - - Single or multiple missiles or pellets are fired from the same
shell, each of which is high-velocity when at close range.
Shotgun, "Sawed-off" - - A shotgun with a shortened barrel which allows
easier concealment by criminals. The spread of the pellets is much great-
er than with a standard-length barrel or "choke," so, that fewer pellets ~vill
hit the target as the distance increases from 6 to~f2 feet. A sawed-off
shotgun blast at a range of more than 12 feet may cause only minimal
trauma unless a vital structure is injured.
Small caliber - - Arbitrarily less than 0.60 inch caliber;2 includes all civilian
weapons.
Special s h e l l - Extra gunpowder in the shell.
Standard s h e l l - Regular amount of gunpowder in the shell.
Tumbling - - Forward rotation around the center of mass of the bullet. NOF
mally does not occur until a bullet has lost so much velocity that it could
not penetrate the skin, 7 but the M-16 was designed to tumble, thus dis-
sipating more energy to the tissue and circumventing the Geneva Con-
vention, which tried to limit the amount of energy dissipation in the tissue.
Yaw - - Deviation of a bullet in its longitudinal axis from straight line of flight.
Annals of Emergency Medicine 13:12 December 1984
tissues. This seems logical: bone, for jacketed. This will release less energy eted bullet. This is evident, from the
example, would be better able to slow than if the buffet were a "dumdum." observations that the bullet did not
a bullet than would muscle or lung Note that the bullet actually turned have enough energy to penetrate the
tissue, and is in turn more likely to be when it hit the bone so as to lay chest wall, it did not cause a fracture
damaged or will be m o r e severely along the longitudinal axis of the even though it is lying against the
damaged than the less dense tissues. bone. Obviously this is a low-energy sternum, and its shape is perfectly
Formulas used to calculate this re- missile (evidenced by the fact that the preserved. Serious injury should only
tardation have been expressed as a humerus did not even fracture) and be present if this bullet caused a con-
drag coefficient, using water and gela- thus was travelling at between 150 cussive force to the lung or the heart.
and 195 feet~second when it hit. This bullet was probably travelling at
Fig. 3. Radiograph shows a .38-caliber Fig. 4. This chest film shows two bul- between 150 and 195 feet/second. The
bullet resting against a humerus. The lets. The bullet in the anterior chest second bullet is resting in the soft
bullet is nondistorted, and therefore is wall is a .45-caliber, low-energy jack- tissue over the dorsal spine. This bul-
let has been deformed into the shape
of a ball, and fragmentation is visible.
Therefore, this bullet was probably
1338 - - First western military use of firearms by French attacking South-
not jacketed. It is difficult to state the
ampton.
caliber accurately because of the de-
1761 - - John Hunter, in the Belle Isle Expedition, reported that it "is possible formity, but it w o u l d be approx-
to predict the extent of tissue damage in fresh gunshot wounds." imately .45-caliber. The fact that the
1894 - - Sir Victor Horsley found that tissue disruption is due to high velocity bullet did not enter the chest cavity
and the spin of the bullet. 8 or break bone means that it was low-
1898 - - Woodruff described cavitation in high-velocity wounds. 9 energy when it hit the chest, and it
1927 - - Wilson defined basic principles: The wound effect depends on 1) could be a .45-caliber "'dumdum"
amount of energy transmitted to the tissues, 2) velocity, 3) direction of fired at more than 50 yards or a par-
transmitted energy, and 4) density of the tissues, lo tially jacketed hollow-tip fired at
somewhat closer range. Serious injury
1 9 4 0 - High-speed photography confirmed the cavitation theory. 2 should only result if vital structures
have been hit.

13:12 December 1984 Annals of Emergency Medicine 1115/69

WOUND BALLISTICS
Ordog, Wasserberger & Batasubramanium
Fig. 5. A large-caliber bullet (approx-
i m a t e l y .45-caliber) has caused a
comminuted fracture of the proximal
femur while leaving multiple metallic
fragments in the wound. Jacketing is
generally not visible on x-ray films,
and it is difficult to determine ff this
bullet was jacketed. This bullet is of
higher energy than those previously
shown, but was not of high velocity.
The bullet is still within the soft
tissue, and therefore cavitation prob-
ably did not occur. Serious injury can
result from this high-energy wound,
including vascular and neurologic
damage. This wound requires a mod-
erate a m o u n t of debridement, but
there should be less than 2 cm of de-
vitalized tissue in each direction from
the wound tract.
Fig. 6. This bullet wound to the femur
was caused by a high-velocity large-
caliber bullet which may have been
nonjacketed, because the wounds are
large (entrance over the greater
trochanter and exit at the medial side
of the thigh), the exit wound is larger
than the entrance (note the spread of
70/1116
the metallic fragments at the exit
site), the femur has actually exploded
instead of just fracturing, and even
though the bullet passed through a
large bone it still had enough energy
to exit the body. Cavitation is.visible
from the distribution of the metallic
fragments. This type of missile is Cery
destructive, and the wound m a y re-
quire extensive debridement.
tin as models, which m a y be similar
to body tissues:
Drag coefficient (CD) =
KD x P x V2 x d 2
where KD is summation of other fac-
tors affecting the bullet, P is density of
the tissue, V is velocity, and d is diam-
eter of the bullet. Thus the drag coeffi-
cient also is greatly dependent on im-
pact velocity and bullet diameter. The
other factors involved in missile drag
KD are related to missile composition,
shape, design, and the way the bullet
behaves in flight.
Missile shape is important in drag,
Annals of Emergency Medicine
in both the air and the body tissues.
The ballistic coefficient {which is in-
versely related to air drag) is not im-
portant at target ranges of less than 50
yards for civilian handguns and 100
yards for a high-velocity weapon. Be-
y o n d these ranges, however, a bullet
with a low ballistic coefficient will
lose less velocity than will one with a
high ballistic coefficient:
SD
Ballistic coefficient {C) = I
where SD is sectional density-(bullet
w e i g h t / 7 , 0 0 0 , x diameter 2) and I is
bullet ogive {radius of bullet curve in
the lateral projection).
Pointed bullets (Spitzer) have a high
ogive value (I) and thus a lower bal-
listic coefficient t h a n do b l u n t or
round-nosed bullets, and therefore are
less likely to lose velocity at greater
distances. T h e M-16 bullet, w i t h a
high ballistic coefficient, can kill a
man at more than 300 yards.
Bullet c o m p o s i t i o n is important.
Most bullets are made of lead or an
alloy of lead. Lead has a high specific
gravity and thus can carry more mass
13:12 December 1984

or weight per volume than can most
other metals, resuking in less air drag
per mass as well. 12 Pure lead bullets
melt at velocities greater than 2,000
feet/second. To counteract this, the
bullet has been jacketed with an outer
layer of another metal that has a high-
er melting point. This jacketing also
maintains the bullet shape in air as
well as in body tissue. The jacket may
be formed of aluminum, brass, bronze,
steel, or teflon, among other sub-
stances.
By the Geneva Convention, all mili-
tary bullets must be fully jacketed.
Jacketed bullets maintain their diame-
ter throughout air and tissue passage.
They are more likely to pass through
the tissue, and tend to be less altered
in shape. Partially jacketed bullets
(dumdUm, m u s h r o o m , expanding,
soft-nosed, or sporting bullets) are
more likely to Increase their diameter
in tissue, therefore increasing tissue
drag (as a function of increased surface
area) and imparting more energy to
the tissues in a shorter distance than a
jacketed bullet. A partially jacketed
bullet may expand and stop when it
reaches a structure of high specific
gravity, such as bone, but in doing so
it imparts more energy to the bone
than would a jacketed bullet that may
pass right through the bone.
Nonjacketed bullets can expand to
three times their original diameter, 3
equal to four times the surface area,
allowing for more energy transmission
to the tissues and creating a wider
wound tract. The experiments of De-
13:12 December 1984
Muth 12 showed that in comparing
similar jacketed versus nonjacketed
bullets the entrance wounds were
similar, but the exit wounds of the
nonjacketed bullets were six times
greater in diameter. The volumes of
the wound increased markedly, from
23.5 m m 3 to 917 m m 3 for jacketed
versus n o n j a c k e t e d bullets of the
same caliber and velocity.
A further modification in bullet de-
sign is the so-called "hollow-point"
bullet, a partially jacketed or un-
jacketed bullet in which the tip is hol-
lowed out to form a concavity. This
increases air drag substantially by de-
creasing the ogive value of the bullet,
and thus it must be used at short
range. More importantly, the hollow-
point greatly enhances the mush-
rooming effect of the bullet, thus im-
parting even more energy to the
tissues and causing more tissue de-
struction in a shorter distance in the
tissue than does even the unjacketed
bullet. These bullets also are less like-
ly than jacketed or partially jacketed
bullets to exit a body. This is sup-
posedly the rationale for the use of the
hollow-point bullets by some law en-
forcement agencies; the bullet is more
likely to remain within the criminal's
body, and less likely to exit and hit in-
nocent bystanders.
The Geneva Convention tried to
limit the amount of tissue damage in
a war by requiring jacketed bullets,
supposedly so that a soldier could be
i m m o b i l i z e d with a m i n i m u m of
tissue damage and morbidity.
Annals of Emergency Medicine
Fig. 7. This .45-caliber bullet is jack-
eted; the bullet has maintained its
shape. Even though the bullet frac-
tured the radius, it came to rest be-
side the bone and therefore was at rel-
atively l o w energy at the time it
entered the arm. Minimal soft-tissue
destruction should be evident.
A fully nonjacketed bullet fired at
low velocity may mushroom so much
that it does not even penetrate the
skin, dissipating its energy in chang-
ing shape to a large flat object. Even
though it may not penetrate the skin,
extensive damage through blunt trau-
ma may still be done.
Some further modifications of bul-
lets have been made to produce even
more brutal injuries. Hollow bullets
have been filled with various particles,
such as phosphorus, gunpowder, and
teflon, thus either burning or explod-
ing on impact or sending a shower of
foreign bodies into the w o u n d s .
Teflon-coated bullets do not deform
even when confronted with a bullet-
proof vest, and thus are able to pene-
trate even protected chests and ab-
domens.
In addition to the behavior of the
bullet in flight and in the tissue, the
angle of impact of the bullet on the
target can greatly influence the drag
coefficient and the amount of tissue
damage. The more acute the angle to
the skin, the more surface area is pre-
sented to the tissue, thus increasing
the wounding energy and amount of
tissue destruction.
Aerodynamic factors alter the flight
of the bullet from its spin-stabilized
flight. These same factors occur in the
tissue as well, resulting in yaw, tum-
bling, precession, and nutation. 6 Any
of these motions of the bullet in air
will tend to increase the air drag, as
more surface area of the bullet is pre-
sented to the air stream. In tissue,
however, the effect of these motions is
to increase energy dissipation and
therefore exacerbate tissue destruc-
tion. An example of this is the design
of the M-16 bullet, which tumbles
through the tissues, causing substan-
tial tissue damage while at the same
time adhering to the Geneva Conven-
tion by being jacketed, The entrance
wound of an M-16 bullet may be rela-
tively small, but if the bullet exits this
wound can be considerable. The same
jacketed bullet that does not tumble
through the tissues would have sim-
ilar-sized entrance and exit wounds,
1117/71
WOUND BALLISTICS
Ordog, Wasserberger & Balasubramanium

Fig. 8. A solitary .22-caliber bullet in

the soft tissue of the neck. Do not use TABLE 1. Comparison of frequently used bullets 2,6,11,12
this x-ray to evaluate bullet size be-
cause the bullet is being viewed from
its base. This bullet is jacketed (shape Bullet Muzzle Muzzle
is maintained) and of low energy be- . Weight Velocity Energy
cause it barely broke the skin (not ap- Weapon (grains) (ft/sec)_ (ft-lbs)
parent from this x-ray alone). Serious
injury usually will result only if the Handguns
bullet hits a vital structure. 32 71 863 91
45 230 850 370
Fig. 9. This .357-caliber bullet is jack- 45 Colt 250 860 410
eted; the shape was maintained. It 38 Special 158 1,090 425
was of low energy, possibly after being 357 Magnum 158 1,415 695
fired from a great distance, because it 44 Magnum 240 ....-%470 1150
passed through only half the tissue of
the neck. This wound should not de- Rifles
vitalize much tissue, but the patient 22 Remington 40 1,180 124
died because the bullet severed the M-16 55 3,200 1,248
carotid artery, internal jugular vein, 22 Swift 45 4,140 1,825
and the spinal cord at C-5. 30-30 Winchester 170 2,200 1,830
303 British 215 2,160 2,230
Russian 7.62 150 2,810 2,635
but w o u l d cause far less tissue de- M-14 180 2,610 2,720
struction. M-1 172 2,700 2,785
After velocity of the bullet, tissue 8-mm Mauser 170 2,530 2,415
yaw is the second most important fac- Mauser Mod 98 198 2,650 3,031
tor in tissue destruction, at least for 357 H and H Magnum 270 2,720 4,440
the standard type of bullet33 Perfect
spheres have no yaw, and military bul-

72/1118 Annals of Emergency Medicine 13:12 December 1984

lets while in flight through air have
less than 3% yawJ 3 Once the bullet
hits the target, the yaw will vary
greatly depending on the angle of im-
pact and variations in tissue density as
the bullet passes through the body.
The increase in cross-sectional area
due to yaw causes greater deceleration
and release of damaging energy to the
tissues. Passing through variations in
tissue density (for example, from mus-
cle to bone to lung) will change the
yaw. Yaw in a bullet is another factor
that causes the exit wound to be
larger than the entrance wound. If
shot at close range Straight on, the
M-16 bullet also has very little tissue
yaw, and the entrance wound may be
larger than the exit wound because
more energy is imparted at the en-
trance site than at the exit. 14
MECHANISM OF TISSUE
DAMAGE
Tissue damage due to bullets stems
from three mechanisms: laceration
and crushing, shock waves, and cavita-
tion.
Crushing and laceration is produced
13:12 December 1984
by the direct force of the bullet mov-
ing the tissues in its path. This is the
principal mechanism of injury in low-
velocity gunshot wounds, caused by
alt handguns, low-velocity rifles, and
all military gunshot wounds prior to
World War I. The amount of crushing
and laceration that occurs depends on
missile velocity, the shape and com-
position of the bullet, and the angle of
impact and the flight characteristics,
such as yaw, precession, tumbling, and
nutation. Crushing and laceration
cause serious injury only if the bullet
actually strikes vital organs and blood
vessels. Low-velocity missiles have
been shown to injure blood vessels by
pushing the vessel ahead and then
penetrating it.
Shock waves are generated by high-
velocity bullets tgreater than 2,500
feet/second) in tissue due to compres-
sion of tissue ahead of the bullet. The
region of compression moves away
from the bullet in all directions at a
speed greater than the bullet itself (at
approximately the speed of sound in
water, or 4,800 feet/second). While the
shock waves last only for 15 to 25 mi-
Annals of Emergency Medicine
Fig. 10. This bullet is a .38-caliber
jacketed bullet of low energy. The
bullet is viewed from its base in this
x-ray, and the caliber can be deter-
mined by measuring the diameter in
hundredths of an inch. The shape is
maintained and the bullet is of low
energy; it has come to rest within the
joint space with minimal destruction
of bone or soft tissue. Only the
clinoid process has been damaged.
Fig. 11. This .38-caliber bullet is jack-
eted and of low energy; it only passed
several inches into the body, despite
this being an area of low specific grav-
ity The hmg is of low specific gravity,
so m i n i m a l energy release occurs
here. No fractures have occurred, no
p n e u m o / h e m o t h o r a x was formed,
and actually (surgical finding) the
bullet came to rest against the per-
icardium because the energy was not
great enough to penetrate it. The pa-
tient did not demonstrate a cardiac
contusion.
croseconds, they are of high energy,
creating more than 1,000 pounds per
1119/73
WOUND BALLISTICS
Ordog, Wasserberger & Balasubramanium

Fig. 12. This .32-caliber bullet shows

what happens when the bullet is non-
jacketed. Even though this bullet is of
low energy, it releases energy sud-
denly when it strikes a structure of
high specific gravity. The bullet frag-
mented and was able to fracture two
bones before it stopped. This wound
will not require extensive debride-
ment, and vital structures will be in-
jured only if they are hit directly. Cav-
itation did not occur.
Fig. 13. Shotgun pellets of small size
are referred to as "bird-shot." A shot-
gun at close range is considered a
high-velocity and, therefore, a high-
energy weapon. A shotgun with a reg-
ular-length barrel will result in spread
of the pellets of approximately 1 cm
for every five feet of distance. A
"sawed-off" shotgun has its barrel
shortened, which results in a much
greater spread of the pellets, but also
m a k e s the weapon ineffective at a
range of more than a few feet. The pel-
lets in this x-ray are spread at approx-
imately 4 cm between pellets, so this
may have been a regular shotgun at
TABLE 2. Comparison of specific gravity with wound severityZ~2
Tissue
Fat
Liver
Skin
Muscle
Lung
Bone (rib)
great distance or a "sawed-off" shot-
gun at a closer range. Bone fracture
has not occurred, and injury should
be confined to local tissue. These pel-
lets were actually removed from the
skin with forceps.
s q u a r e i n c h of p r e s s u r e . 13 S h o c k
waves cause little damage to muscle
and bone but can easily injure or rup-
ture gas-filled organs, is
Cavitation can be created by bullets
traveling at greater than 1,000 feet/sec-
Specific Gravity Wound Severity
O,8 Moderate
1.01,q .02 Ma[ked
1.09 , MarRed
1.02-1.04 Marked
0,4-0.5 Minimum
1,11 Extreme
ond, including all bullet's from rifles
and f r o m special or m a g n u m hand-
guns. Force moves the tissues forward
and lateral to the bullet with an iner-
tia such that the motion continues for
a few milliseconds after the bullet has
passed. This creates a cavity which
has subatmospheric pressure, thereby
sucking air into the entrance and exit
wounds. The size of the cavity created
depends on the type of tissue in-
volved. The cavity pulsates inward, in
gradually decreasing sizes until it col-
lapses or fills with air at atmospheric

74/1120 Annals of Emergency Medicine 13:12 December 1984

pressure. 13 A permanent cavity re-
mains which is usually much smaller
than the temporary cavity before it
collapsed. Thus examining the wound
may reveal little to indicate the extent
of the actual tissue damage. A direct
relationship exists a m o n g the ab-
sorbed missile energN, the peak cavity
volume, and the irreversible tissue
damage. 16 The effect of cavitation in
higher velocity gunshot wounds is
much more significant than that of
shock waves to all areas except, possi-
bly, the abdomen.
Cavitation stretches the smaller
blood vessels, shearing and rupturing
them as well as nerves and even bone.
This causes permanent bruising, or if
t h e e l a s t i c i t y of the s u r r o u n d i n g
tissues is incapable of containing the
temporary cavity, the structure ex-
plodes and the tissue is blown out-
ward permanently. 17 Again, this can
occur with any missile travelling at
more than 1,000 feet/second, and thus
excludes all handguns except the spe-
cials a n d magnums and includes all
types of rifles.
Abdominal cavitation occurs when
bullets traveling at more than 1,000
feet/second enter the abdomen. High-
speed photography has shown that at
least two oscillation cavities form,
each for only millisecondsA7 The first
cavity is of short duration but high in-
tensity. The second cavity lasts longer
but is of lesser intensity, usually caus-
ing most of the damage. Air does not
enter these cavities; instead, the ab-
domen collapses from atmospheric
pressure after cavitation. Gas-filled
structures can be damaged by the
negative pressure during the process.
Radiographs show that bowel gas in-
creases in v o l u m e as the c a v i t y
enlarges, possibly resulting in multi-
13:12 December 1984
ple perforations anywhere in the ab-
domenA7 Obviously the size or loca-
tion. of t h e e n t r a n c e a n d / o r exit
wounds has no correlation with the
findings of vascular injuries, visceral
tears, mesenteric disruption, or gas-
filled viscus ruptures in abdominal
gunshot wounds from bullets travel-
ing at more than 1,000 feet/second.
Vascular injury due to missiles shot
at more than 1,000 feet/second has
been shown to occur by neat shearing
of the vessel without stretching it
first, as with low-velocity missiles.
This is followed by cavitation that
damages a more extensive area of the
blood vessel, possibly extending for at
least 20 m m on each side of the bul-
let's pathA8,19
The cavitation effect of a missile
may produce a cavity that is 30 to 40
times the diameter of the bullet. 6 This
is the area of devitalized tissue (which
usually does not bleed with incision),
and complete debridement of this area
is usually required. Consequently the
risk of infection in wounds from high-
velocity missiles is much greater than
that from lower velocity missiles.2O, 21
LOW-VELOCITY BULLETS IN
VARIOUS TISSUES
Low-velocity missiles are relatively
unstable compared to high-velocity
missiles because of lower kinetic ener-
gy. After penetration of the skin, even
less kinetic energy remains to damage
other organs. Low-velocity bullets
tend to follow tissue planes, and often
do not follow a straight line from the
entrance to their place of rest. Because
of deviations in their course, the bul-
lets m a y m o v e around i m p o r t a n t
structures w i t h o u t h a r m i n g them.
These bullets also may end up in a lo-
cation of the body completely un-
Annals of Emergency Medicine
Fig. 14. (Far left) N o n j a c k e t e d or
"dumdum" 38-special bullet. (Second
from left) Partially jacketed bullet,
but the tip has been removed and the
bullet hollowed out. This "hollow-
point" 38-special is the standard issue
ammunition of the Los Angeles Police
D e p a r t m e n t . (Second f r o m right)
Non jacketed .35-caliber regular am-
munition with a shorter shell and so
less gunpowder than the two specials
to the left. (Right) Fully jacketed .35-
caliber standard ammunition.
Fig. 15. Another view of the same bul-
lets as in Figure 12. The hollow-point
bullet has been rotated to show that
the bullet has been hollowed out.
This increases the mushrooming ef-
fect of the bullet when it hits tissue,
resulting in more local tissue destruc-
tion.
suspected from the physical examina-
tion. All appropriate roentgenograms
should be obtained until the missile is
located. When bone is encountered in
the bullet's internal flight, and it can-
not course around the bone, much of
its energy may be spent fracturing the
bone, at which point the bullet will
stop. 3
BULLET STERILITY
Fired bullets are not sterile because
insufficient heat is generated. Experi-
ments have shown that even high-ve-
locity missiles, if contaminated with
bacteria prior to firing, will inoculate
a sterile m e d i u m with these bac-
teria.ZZ,z3 Other secondary projectiles,
such as skin, clothing, gunpowder de-
bris, surrounding i n a n i m a t e struc-
tures, and shotgun shell wadding may
carry potentially pathogenic bacteria
that may delay wound healing. These
1121/75
WOUND BALLISTICS
Ordog, Wasserberger & Balasubramanium
foreign bodies m u s t be removed by de-
bridement or irrigation. 20
SIZE OF THE BULLET
ON RADIOGRAPH
In calculating the size of a bullet
from radiographs, magnification of the
object m u s t be t a k e n i n t o account.
Magnification24 is defined and mea-
sured as:
Size of the image
M = Size of the object
Practically, to measure the size of the
bullet from a radiograph the formula
used is the following:
(focus: object distance
image size) x
image size
Object size = focus: film distance
where object size is actual size of the
bullet, image size is'size of the bullet
on x-ray" focus: film distance is dis-
tance from the x-ray tube to the film,
and focus: object distance is distance
from the x-ray tube to the actual bul-
let.
In actual use, w h e n viewing bullets
in the h u m a n body the magnification
will range from zero to a m a x i m u m of
25%. For example, a bullet in the an-
terior chest on a PA chest film where
the bullet is up against the x-ray film,
using the usual focus: film distance of
six feet, no magnification will occur.
The greatest c o n c e i v a b l e magnifica-
tion will result when an AP chest film
is taken at a distance of three feet and
the bullet is in the anterior chest wall.
Here the focus: film distance is mini-
m u m and the focus: object distance is
m a x i m u m , resulting in a 20% magni-
fication by calculation. For practical
purposes, if the bullet is close to the
x-ray film (proven by taking a lateral
film as well), magnification m a y be
discounted in e s t i m a t i n g bullet size.
Other circumstances will require use
of the above formula.
76/1122
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SUMMARY
It is important to identify the type
of bullet and the type of gun or rifle
used i n order to disclose essential in-
formation about the severity and ex-
tent of an injury based on the theories
of w o u n d ballistics. Knowing the type
of weapon and bullet allows estima-
tion of the missile velocity and kinet-
ic energy which determine the type of
injury that results (specifically, lacera-
tion and crushing compared to shock
wave or cavitation). This knowledge
may determine the extent of the in-
vestigational procedures used to evalu-
ate the patient, as well as the extent of
the surgical debridement and repair
necessary for each individual wound.
A thorough knowledge of wound bal-
listics is mandatory for all physicians
who m a y be involved in the care of
gunshot w o u n d Victims.
REFERENCES
1. Rich NM: Missile injuries. A m l Surg
1980;139:414-420.
2. Adams DB: Wound ballistics: A review.
Milit Med 1982;147:831-835.
3. Holt GR, Kostohryz G Jr: Wound bal-
listics of gunshot injuries to the head and
neck. Arch Otolaryngo11983;109:313-318.
4. Finck PA: Ballistic and forensic patho-
logic aspects of missile wounds. Milit
Med 1965;130:545-550.
5. De Muth WE: Ballistic characteristics
of "magnum" sidearm bullets. J Trauma
1974;14:227-229.
6. Whelan TJ (ed): Emergency War Sur-
gery, First US revision. NATO Handbook.
Washington, DC, US Government Print-
ing Office, 1975.
7. Callender GR: Wound ballistics: Stud-
ies in the mechanism of wound produc-
tion by rifle bullets. Milit Surg 1935';
77:177-182.
8. Horsley V: The destructive effects of
small projectiles. Nature 1894;50:104.
9. Woodruff CE: The causes of the ex-
plosive effect of modern small caliber bul-
lets. N Y Med J 1898;67:593.
Annals of Emergency Medicine
10. Wilson LB: The Medical Department
of the United States Army in the World
War. Washington DC, US Government
Printing Office, 1971, vol II.
11. DeMuth WE, Smith JM: High-velocity
bullet wounds of muscle and bone: The
basis of rational early treatment. J Trau-
ma 1966;6:744-755.
12. DeMuth WE: Bullet velocity and de-
sign as determinants of wounding capaci-
ty: An experimental study. J Trauma
1966;6:222-232.
13. Hopkins DAW: Firearm injuries. Br J
Surg 1967;54:344.
14. Dimond FC: M-16 rifle wounds in
Vietnam. J Trauma 1967;7:19.
15. Harrell JB: Hollow-point ammunition:
Injuries experienced in a police group. J
Trauma 1979;19:115-116.
16. Matheson JM: Infection in missile
wounds. Ann Roy Coil Surg Engl 1968;
42:347.
17. Puckett WO: Studies on wounds of
the abdomen and thorax produced by high
velocity missiles. Milit Surg 1970;101:
167-169.
18. Amato l Jr: Vascular injuries: An ex-
periment of high and low velocity missile
wounds. Arch Surg 1970;101:167.
19. Amato J Jr: High velocity arterial in-
jury: A study of mechanism of injury. 1
Trauma 1971;11:412.
20. Stutzman RE: Ballistics and the man-
agement of ureteral injuries from high ve-
locity missiles. J Urol 1977;118:947-949.
21. Parker JM: Re-emphasizing the impor-
tance of u r i n a r y tract diversion and
splinting in injuries of the upper third of
the ureter. I Urol 1971;106:368-370.
22. Torsby FP: The mechanism of prima-
ry infection of bullet wounds. Br J Surg
i967;54:359-360.
23. Wolf AW: Autosterilization with low-
velocity bullets, l Trauma 1978;19:115-
116.
24. Christensen EE, Curry TS, Dowdey
JE: An Introduction to the Physics of Di-
agnostic Radiology, ed 2. Philadelphia,
Lea and Febiger, 1978, p 153-212.
13:12 December 1984