Table 2

Ballistic head injuries suffered by military personnel

Location and dateHead injury type (main)Head injury cause (main)Comments
WWI2625% head injuries were fatal before helmets introduced
14%–22% head injuries were fatal after helmets introduced
Major cause of injury was fragmentationThe authors concluded that wearing military helmets reduced injuries
Proportion of fragment to bullet injuries not reported
Data from 1918 reported ∼12% head injury rate
New Georgia27 1943 and Burma 194474 head injuries
30 fatalities due to head injuries (locations: 28 brain, four face and neck)
Head injuries caused in equal numbers by rifle bullets, machine gun bullets (major cause of fatalities 6/25), mortar fragments (9/11), artillery fragments, grenades (9/10)Study of 369 injured US soldiers
The M1 helmet typically not perforated in fatalities suggesting it provided adequate protection. Author commented that an increased area of coverage might be beneficial. The unprotected upper face was the most common point of entry in fatalities
Bougainville Island28 194420% of wounded and 49% of KIA personnel received at least one wound to the ‘head, face, neck55% fatal head wounds were caused by rifle bullets and 77% by machine gun bulletsStudy of 1569 Allied casualties (15 February 1944 and 21 April 1944); 10% KIA
Cause of injuries was further broken down: mortars (659), rifle bullets (393), grenades (205), machine gun bullets (151) and artillery (151). Those wounded by fragments were more likely to survive. The authors commented on the vulnerability of the face as an impact zone and the success of Japanese marksmanship in targeting the head
Italy29 WWII131 head wounds
40% received injuries to head and face
Fragmentation was the major cause of fatalityStudy of 983 American service personnel casualties
Korea30 1950–19511275 wounds occurred to the head (including the face) and neck
Data were further broken down into more specific regions, including the skull (i) 64 frontal (54 penetrating), (ii) 48 temporal (47 penetrating), (iii) 30 occipital (23 penetrating) and (iv) 74 parietal (71 penetrating)
Battlefield casualty survey of US personnel (November 1950 to May 1951). Total number of wounds=7773
Fragments caused 92% of casualties and small arms caused 8% of casualties
Korea30 1950–1951375 head injuries
38 face injuries
For ‘died of wounds’ personnel, 14/125 suffered brain damageStudy of 1500 KIA United Nations personnel (January 1951)
Korea30 1950–195176 wounds to the head (15 posterior)Study of 950 wounds suffered by 286 WIA Turkish Brigade personnel
Cyprus Emergency31 1955108 head injuries (including accidents)
38 fatalities due to head injuries
Study of 491 UK military casualties after State of Emergency declared 26 November 1955. Cause of casualties: bombs (256), bullets (177), mines (40)
Vietnam32 1967–19681025 fatalities suffered one or more head injury
454 fatalities were caused by single wounds
Study of 2600 US combat fatalities (1967–1968)
Author noted that the majority of casualties wore armour and that the unprotected areas of the face and neck were particularly vulnerable particularly when personnel were in the prone position
WWII, Korea and Vietnam33Brain injury fatalities 34%–40%
Author suggested that penetrating brain wounds could result in 10%–14% postoperative mortality; if WWI data were included this surgical mortality value for head injuries increased to 40%
Comparison of US Army combat deaths from WWII, Korea and Vietnam. Author suggested that postoperative mortality improvements due to effectiveness of helmet and improved surgical practice. Author recommended that head and neck injuries should be separated in future studies
Belfast34 197465 fatal head injuries108 gunshot injuries to the headStudy of 1373 injuries suffered by UK service personnel (1972–1974). Included 236 fatalities (17% of total)
21% of all injuries were caused by bomb blasts or mines and 24% during rioting (no body segment data were provided). Author suggested that the issued flak jacket reduced injuries
Belfast35 1971–197465 personnel were wounded in the ‘head or neck
46 fatal head injuries
41 personnel wounded in the head by bulletsStudy of 1357 injuries suffered by UK service personnel (1 January 1971–31 December 1974)
Of 236 fatalities, 135 were caused by bullets and 81 fatalities were caused by explosive devices
Falklands36 198236 casualties sustained head and neck woundsOne fatal ‘gross’ brain damage caused by gunshotStudy of 233 UK casualties operated on by Army Field Surgical Teams during the Falklands War (2 April 1982–14 June 1982). Three fatalities; 38 wounds were caused by bullets, 105 by fragments, 25 by mines and 29 were not reported. Surviving casualties with head injuries were injured by low velocity rather than high velocity projectiles
Lebanon37 19829% of fatal injuries occurred to the helmeted head; 74% of these occurred to the frontal bones
22% of fatal injuries occurred to the face; the area between the lips and the zygomatic bones was particularly vulnerable receiving 10% of all impacts
7% fatal head injuries caused by fragments
15% of fatal head injuries caused by bullets
Study of 164 Israeli fatalities from the Lebanon War (6 June 1982–20 September 1982). 405 penetrating injuries; 90% occurred to the front of the body
The authors suggested increasing the protection offered to the front bones of the cranium and adding a rim to the helmet and facial protection to improve protection from projectiles orientating from overhead
Gulf2 1991Four patients with penetrating head injuriesFragmentsStudy of 1053 patients with injuries that occurred during the Gulf War and were treated in a British Field Hospital (20 January 1991–6 March 1991). 63 patients had penetrating injuries (31 British, 29 Iraqi, three Egyptian). 80% of the penetrating injuries were caused by fragments
Gulf38 199124 personnel suffered a head wound; seven suffered only a head wound. Some further breakdown of injury location was included eye (8), face (7), suboccipital (1), temporal (1), unknown (3)
Two soldiers suffered penetrating brain injuries (below helmet trim line: supraorbital (1), subfrontal (1))
95% of personnel were injured by fragments and 5% by bulletsStudy of head injuries suffered by US Seventh Corps hospitalised during Operation Desert Storm (20 February 1991–10 March 1991). Total number of injuries 143 (head injuries 17%). The authors suggested that the inservice helmet and body armour provided good protection
Gulf38 1991Further breakdown of location: parietal (8), frontal (6), frontotemporal (1), frontotemporal parietal (1), temporal (1), orbital (1), frontal (1)Study of 19 penetrating head injuries suffered by Iraqi soldiers. Author noted that there are more penetrations through the vault compared with injured US service personnel as the Iraqis wore no helmets or older metal helmets
Northern Ireland39 1970–198426 fatalities suffered only head injuries; 122 fatalities suffered combined chest and head injuries (86 suffered fragmentation injuries)External injuries were primarily caused by fragmentation or impacting a hard surfaceStudy of blast injuries suffered by 828 UK servicemen in Northern Ireland between 1970 and 1984. Of the 291 personnel killed, 90% wore body armour and 20% wore helmets. The author concluded wearing helmets could save more lives
Somalia40 1998–199914 fatal head injuriesFive fatal head injuries due to gunshot (in four cases the bullet impacted outside the area of coverage of the helmet, in the fifth case the helmet was not worn)Study of 125 combat US casualties in Somalia (July 1998–March 1999)
55% of injuries caused by bullets, 31% of injuries caused by fragments. One Ranger sustained a gunshot to the head that penetrated his helmet but did not penetrate his skull; the Ranger suffered scalp laceration, brain contusion and momentary blindness. The authors suggested that incidence of fatal head wounds would have been higher if helmets had not been worn
Bosnia and Herzegovina41 1999–200219 British head injuriesA retrospective analysis of 1864 casualties admitted to a medical unit in Bosnia and Herzegovina (1 October 1999–30 September 2002) suggested that ∼44% were military personnel; 525 casualties were British
Jerusalem42 2000–200434% of head injuries were caused by secondary fragmentation
16% of head injuries were caused by gunshot
Study of 1500 ‘terror-related’ patients admitted to Hadassah Ein-Kerem University Hospital in Jerusalem between 2000 and 2004. 34% of gunshot injuries and 20% of secondary fragmentation injuries were suffered by Israeli soldiers. The mean length of stay in hospital was similar irrespective of causative agent (fragmentation ∼14±16 days; gunshot 12±24 days)
Kashmir Valley43
23% of combat fatalities due to head injuriesStudy of Indian Army fatalities sustained due to combat injuries in the Kashmir Valley (January 1999–December 2006). Of all fatalities, 78% were due to gunshot and 21% due to IEDs
Iraq44 200329 head and neck injuriesProspective analysis of 294 US casualties admitted to Walter Reed Army Medical Center between 1 March 2003 and 1 July 2003 as a result of Operation Iraqi Freedom
A similar proportion of injuries were due to gunshot, blast and shrapnel and blunt or vehicle accidents (39%; 31%; 34%)
Israel45 2002Three injuries to the head (helmeted area)Two bullets (anterior)
One fragments (inferior margin of the occipital)
Study of 149 injuries in 26 fatal incidents for the Israeli Defence Force (30 March 2002–22 April 2002)
Iraq46 2003Seven head injuries admitted to ICU (four open head injuries)Study of 1429 casualties presenting between 17 March 2003 and 30 April 2003 (Op TELIC) at a Field Hospital
11% of patients were coalition military, the remaining being civilian (54%) and prisoners of war (28%)
Iraq47 2003–200421 patients suffered a penetrating head injury
UK military personnel suffered a penetrating head injury
GunshotStudy of 1455 personnel treated by the 22 Field Hospital Emergency Department in Iraq between November 2003 and March 2004 during Operation Telic III. Included 1091 British personnel. 61 combat injuries
Afghanistan48 2006–2009215 patients treated by a neurosurgeonStudy of combat injuries suffered by 11 158 patients attending UK Field Hospitals between April 2006 and April 2009 (Op HERRICK 4–9)
Iraq49 2004–20077123 head, face and neck injuries; 2205 mTBI injury (‘no recorded evidence of intracranial injury, and a loss of consciousness of less than 1 h, or loss of consciousness of unknown duration, or unspecified level of consciousness’)
1841 face injuries
206 neck injuries
A study of 17 627 injuries suffered by male US personnel involved in 4623 explosions that occurred in Iraq between March 2004 and December 2007
Body armour and helmets were worn in ∼90% cases
Afghanistan and Iraq50 2006–2007Personnel with a head injury AIS six accounted for 83% of deaths from head injury (20/24 victims)Study of 76 UK fatalities from Afghanistan and Iraq during 2006–2007; 51 caused by fragments
Injury data were mapped against PPE area of coverage; these results were not made publically available, however, the vulnerability of the face and neck (as opposed to the cranium) was highlighted
Lebanon51 2000–200476 fatal head injuries (occipital and anterior-temporal vulnerable)Bullets76 fatal head injuries suffered by 49 members of the Israeli Defence Forces (2000–2004, 2006, 2009) and caused by bullets were retrospectively reanalysed
The authors suggested that hierarchical protection be incorporated into helmets, so that the occipital and anterior-temporal areas (approximately 15% of the skull) are protected to a greater level (eg, bullet-protection) since these areas suffered approximately 50% of all injuries
UK Joint Theatre Trauma Registry52 2003–2011813 penetrating head injury; 336 fatalities625 fragmentation
188 gunshot
Study of 623 patients from coalition military forces
The authors noted that more severe injuries and worse outcomes occurred for gunshot injuries
Iraq and Afghanistan UK Joint Theatre Trauma Registry53 2003–201433 isolated head injuries
13 head injuries combined with other injuries
61% explosions
39% gunshot
Study of 2985 British military casualties
71 died of wounds (defined as ‘Personnel who die as a result of injuries inflicted by hostile action after reaching a UK or coalition ally Medical Treatment Facility (MTF)’.
  • AIS, abbreviated injury score; DoD, Department of Defense; ICU, intensive care unit; KIA, killed in action; MOD, Ministry of Defence; mTBI, mild traumatic brain injury; PPE, personal protective equipment; WIA, wounded in action; WWI, World War I.