Influence of personal armor on distribution of entry wounds: Lessons learned from urban-setting warfare fatalities

Background: This study was undertaken to examine the distribution of entry wounds resulting from firearms and shrapnel in soldiers wearing military personal armor systems (MPAS) in low-intensity urban combat conditions. Methods: Data were collected for a retrospective analysis on all combat fatalities sustained by the Israeli Defense Force (IDF) between March 30, 2002, and April 22, 2002, during Defensive Shield Operation in the West Bank. Twenty-six of the 30 fatalities were evaluated in the Israeli National Center of Forensic Medicine. Results: A total of 149 entrance wounds were divided into shrapnel and bullet groups. The "face-neck" region had the highest density rate compared with other body regions in both shrapnel and bullet groups (2.97 and 2.41, respectively; p < 0.0001). In both groups, the overall prevalence of anterior injuries was significantly higher than posterior ones (78.9% vs. 21.1% in the shrapnel group and 68.5% vs. 31.5% in the bullet group, p < 0.001). However, anterior and posterior chest injuries had a reverse yet more even distribution (43.8% and 56.2% in the bullet group and 40% and 60% in the shrapnel group, respectively; p < 0.001). The difference in the average diameters of entry wounds in the covered versus uncovered regions (0.79 ± 0.42 cm vs. 0.73 ± 0.29 cm, respectively) was not statistically significant (p = 0.11). Conclusion: The use of MPAS turned the face-neck region into the most vulnerable body part, as shown by its prominent density rate, especially in the shrapnel group. MPAS designed for urban setting warfare should provide maximal shielding both to the anterior and posterior chest regions. The diameter of entrance wounds in the covered versus the uncovered areas was not statistically significant, suggesting that only a minor deformation of the bullet takes place while traversing the Kevlar vest.