• Ahmad Mahajna, Nabil Aboud, Ibrahim Harbaji, Afo Agbaria, Zvi Lankovsky, Moshe Michaelson, Doron Fisher, and Michael M Krausz.
• Department of General Surgery, Rambam Medical Center and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
• Lancet. 2002 May 25; 359 (9320): 1795-800.

BackgroundLow-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.MethodsWe 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.Findings151 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.InterpretationResistance 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.

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