Injury, Int. J.

Care Injured 47 (2016) 1932–1938

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Determining the dimensions of essential medical coverage required by

military body armour plates utilising Computed Tomography
J. Breezea,* , E.A. Lewisb , R. Fryerc
a
Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham Research Park, Birmingham B15 2SQ, United
Kingdom
b
Defence Equipment and Support, Ministry of Defence Abbey Wood, Bristol, BS34 8JH, United Kingdom
c
Platform Systems Division, Defence Science & Technology Laboratory, Portsdown West, Fareham, Hampshire PO17 6AD, United Kingdom

A R T I C L E I N F O A B S T R A C T

Introduction: Military body armour is designed to prevent the penetration of ballistic projectiles into the
Keywords: most vulnerable structures within the thorax and abdomen. Currently the OSPREY and VIRTUS body
Anthropometric
armour systems issued to United Kingdom (UK) Armed Forces personnel are provided with a single size
Plate
Ballistic
front and rear ceramic plate regardless of the individual’s body dimensions. Currently limited
Body armour information exists to determine whether these plates overprotect some members of the military
Anatomy population, and no method exists to accurately size plates to an individual.
Coverage Method: Computed Tomography (CT) scans of 120 male Caucasian UK Armed Forces personnel were
Military analysed to measure the dimensions of internal thoraco-abdominal anatomical structures that had been
Bullet defined as requiring essential medical coverage. The boundaries of these structures were related to three
potential anthropometric landmarks on the skin surface and statistical analysis was undertaken to
validate the results.
Results: The range of heights of each individual used in this study was comparable to previous
anthropometric surveys, confirming that a representative sample had been used. The vertical dimension
of essential medical coverage demonstrated good correlation to torso height (suprasternal notch to iliac
crest) but not to stature (r2 = 0.53 versus 0.04). Horizontal coverage did not correlate to either measure of
height. Surface landmarks utilised in this study were proven to be reliable surrogate markers for the
boundaries of the underlying anatomical structures potentially requiring essential protection by a plate.
Conclusions: Providing a range of plate sizes, particularly multiple heights, should optimise the medical
coverage and thus effectiveness of body armour for UK Armed Forces personnel. The results of this work
provide evidence that a single width of plate if chosen correctly will provide the essential medical
coverage for the entire military population, whilst recognising that it still could overprotect the smallest
individuals. With regards to anthropometric measurements; it is recommended, based on this work, that
torso height is used instead of stature for sizing body armour. Coverage assessments should now be
undertaken for side protection as well as for other non-Caucasian populations and females, with
anthropometric surveys utilising the three landmarks recommended in this study.
Crown Copyright ã 2016 Published by Elsevier Ltd. All rights reserved.

Introduction structures requiring coverage need to be articulated. These are

Body armour is a type of protective equipment worn by military
personnel designed to prevent or reduce injury from ballistic
projectiles penetrating structures within the thorax and abdomen
[1]. To optimise the design of body armour; the anatomical
* Corresponding author at: ST6 Registrar Maxillofacial (Head and Neck) Surgeon,
Academic Department of Military Surgery and Trauma, Royal Centre for Defence
Medicine, United Kingdom.
E-mail address: johno.breeze@gmail.com (J. Breeze).
medical judgments dependent on, for example, distance from a
medical facility and the types of threats requiring mitigation.
Coverage can then be modified by means of a risk-based analysis
that includes human factors considerations such as comfort, fit,
equipment integration and interoperability [2].
A recent multidisciplinary review identified the anatomical
structures of the thorax and abdomen which if damaged would
likely lead to death within 60 min without definitive surgical
intervention: these are the heart, great vessels, spleen and liver [1].
Such essential medical coverage is currently provided to UK Armed
Forces in the form of single sizes of front and rear OSPREY plates

http://dx.doi.org/10.1016/j.injury.2016.06.010
0020-1383/Crown Copyright ã 2016 Published by Elsevier Ltd. All rights reserved.
 J. Breeze et al. / Injury, Int. J. Care Injured 47 (2016) 1932–1938 1933

Fig. 1. The OSPREY hard armour plates providing the front (left) and rear (right) components of thoraco-abdominal essential medical coverage currently provided to UK
Armed Forces personnel.

(Fig. 1); these plates cover all of the aforementioned structures
with the exception of the most inferior portion of the abdominal
aorta and inferior vena cava from front and rear angles (Fig. 2).
Coverage of this area was not possible for ergonomic consider-
ations; for example hard armour is rigid and therefore may limit
the adoption of certain postures, such as sitting within a vehicle.
Anthropometric surveys of military personnel have the poten-
tial to provide data to size and scale body armour to an individual
[3–6]. These in turn could be supplemented by assessments on
computerised geometric representations of human anatomy,
provided the anatomical structures were accurately scaled
(Fig. 2) [7–9]. The most comprehensive anthropometric study of
UK Armed Forces personnel to date was undertaken by QinetiQ,
and measured 2470 subjects (2159 male, of which 1395 were
Caucasian and 924 of these were Army or Royal Marine personnel).
[4]. However the only relevant values in these existing anthropo-
metric surveys, in terms of body armour coverage, is the stature
(standing height) of an individual; this is because, prior to this
study, no evidence exists to link the remaining external measure-
ments to internal anatomical structures. In addition, no work exists
in the literature describing whether or not internal organs simply
scale proportionally with increased height. Both liver and spleen
size have been shown to increase with height but the relationship
shows poor correlation [10–20]; in other structures such as the
pancreas and aorta diameter, taller people have proportionally
smaller structures than shorter people [21,22].
Previous research into helmet and neck coverage demonstrated
that utilising hard tissue (i.e. bone) landmarks for coverage
assessments are more reproducible than soft tissue landmarks as
they do not alter with changes in the subject’s body mass [23,24].
An example for the thoraco-abdominal region is the umbilicus
(belly button), which is commonly believed to be a surface
landmark representing the bifurcation of the aorta (i.e. the lower
border of essential medical coverage) [25–27]. The closest bone
landmark to this is the superior border of the iliac crest of the hip,
but this has never been measured in military anthropometric
surveys before. The only relevant palpable bone landmark for
thoraco-abdominal coverage that has been measured in such
previous anthropometric surveys is the suprasternal notch [3,6].
The suprasternal notch is a potentially useful landmark as it has

Fig. 2. Front (a) and rear (b) OSPREY body armour plates superimposed upon a computerised geometric representation of those internal anatomical structures requiring
essential medical coverage, positioned as fitted in current UK issue carrier. It should be noted that the inferior parts of the vessels not covered by the plates are still covered by
soft armour.
1934 J. Breeze et al. / Injury, Int. J. Care Injured 47 (2016) 1932–1938

been described as being just above the most superior point of the
arch of the aorta (i.e. the upper border of essential medical
coverage) [25–27], and has been used for a number of years to
position ceramic plates in UK body armour vests. As such, torso
height – defined as suprasternal notch to iliac crest (most vertical
points when viewed in horizontal axial plane) – could be related to
essential medical coverage of the thorax and abdomen.
The aims of this research were to determine the size, location
and variation of internal anatomical structures within a military
population from CT scans of UK Armed Forces personnel. These
internal anatomical structure location could then be related to
external bone landmarks to enhance fitting and sizing. Finally the
aim was to exploit the measurements obtained from CT scans to
provide evidence for the size and shape of body armour plates to Fig. 4. A demonstration of how the horizontal distance between the most lateral
optimise the anatomical coverage they provide. points of the liver and spleen were determined from a contrast CT scan. This
distance is the lower horizontal component of essential medical coverage (Distance
Method H).

Contrast CT ‘trauma' scans of 120 consecutive UK Armed Forces
personnel evacuated to the Queen Elizabeth Hospital Birmingham
(QEHB) between 17 June 2009 and 19 March 2013 were analysed.
Stature (vertex of scalp to sole of feet) of these individuals upon
admission to hospital was determined, as recorded by a nurse
using a tape measure or using their military identification card.
These scans were taken as part of the trauma call protocol for all
injured service personnel in Afghanistan as part of their initial
assessment. Analysis of these scans was approved by the Medical
Directorate of the Defence Medical Services.
Scans were excluded if there was any damage to structures
within the thorax or abdomen as well as any in whom stature
information was not available. To increase the statistical strength
of any conclusions made, only scans of male Caucasians were used.
The height measurements were compared to data derived from the
QinetiQ anthropometric study [4] using a two tail z-test with a
significance level of p = 0.01 to ascertain whether this was a
representative sample.
The vertical and horizontal distances between specific soft
tissue and bone landmarks were determined from the CT scans
(Fig. 3). Vertical distances were determined by measuring the
distance between horizontal planes taken at most superior and
inferior points of that structure. Horizontal measurements were
recorded as the distance between the most lateral points of each
anatomical structure (Figs. 4 and 5). Slice thicknesses prior to 16
July 2010 were 1.0 mm and 3.0 mm; after this date 1.25 mm slices
were used.

Fig. 3. A pictorial representations of the measurements made from CT scans using an anatomically accurate three- dimension computer geometrical model.
 J. Breeze et al. / Injury, Int. J. Care Injured 47 (2016) 1932–1938
Fig. 5. Maximum heart diameter was determined to the left (Distance K) and right
(Distance J) of the midline (dashed line). The heart can be seen to sit more to the left
of the midline.
The most superior point of the arch of the aorta (i.e. the upper
border of essential medical coverage) was related to the supra-
sternal notch (distance i, Fig. 6). The bifurcation of the aorta (i.e. the
lower border of essential medical coverage) was related to the
superior border of the iliac crest in the mid clavicular plane
(distance iii). In addition the lower border of the liver was related
to the lower border of the ribcage in the mid clavicular plane
(distance ii). Stature (distance N) and torso height (suprasternal
notch to superior border of the iliac crest, distance G) were
correlated using linear regression analysis to both the vertical and
horizontal components of essential medical coverage.
Results
The clinical heights of the 120 soldiers sampled in this study
ranged from 1690 mm to 1930 mm (Table 2). The heights at each
percentile were compared to the 924 Army and Royal Marine
Caucasian male subjects from the 2007 QinetiQ anthropometric
survey which ranged from 1600 mm to 2014 mm [4]. Using a two
tail z-test with p < 0.01 the null hypothesis was rejected suggesting
Fig. 6. Relating the horizontal components of essential medical coverage to surface bone landmarks; i = arch of the aorta to suprasternal notch (1), ii = lower border of the liver
was related to the lower border of the ribcage (2), iii = bifurcation of the aorta to iliac crest (3). Note the distances are not to scale to enhance visual clarity.
1935
that the CT scan sample was representative. Both total height and
torso height were found to be normally distributed. Calculated
distances derived from CT between thoracic and abdominal
anatomical structures were arranged into percentiles (Table 3).
The three surface (bone) landmarks were able to accurately
represent the position of each underlying soft tissue structure
(Table 4). For example the position of the suprasternal notch
ranged from 20 mm below the aortic arch to 27 mm above it (with a
mean distance of 9 mm above the arch). In 107/120 (89%) CT scans,
torso height (Distance G) was larger than essential vertical
coverage (Distance D). Stature demonstrated poor correlation to
all of the components of essential medical coverage i.e. as height
increases the size of coverage does not necessarily increase. Torso
height demonstrated the best correlation to essential vertical
coverage, but poor correlation to the horizontal parameters
(Table 5); this means that as torso height increases, the vertical
component of coverage increases proportionally. There was poor
correlation between stature and torso height (R2 = 0.011), meaning
that those taller individuals do not necessarily have greater torso
height than shorter individuals.
Within the population sampled, the vertical component of
essential medical coverage (Distance D in Fig. 3 and Table 1), had a
range of 111 mm between the minimum value (305 mm) and
maximum value (416 mm). This suggests that if a single height of
body armour plate is used then this could overprotect a large
proportion of the population. For example, a plate height based on
the vertical component of essential medical coverage from the
50th percentile soldier in this study (353 mm) could theoretically
overprotect the shortest soldier by 48 mm.
The horizontal components of essential medical coverage did
not correlate with either total or torso height i.e. as height
increased the horizontal components of coverage did not
necessarily increase and often decreased. This finding means that
should multiple widths of plate be required, another method of
sizing them is required other than torso height, such as measuring
waist circumference. However, there was little variation in these
horizontal components of coverage across the population.
Therefore choosing a single plate width for the lower horizontal
1936 J. Breeze et al. / Injury, Int. J. Care Injured 47 (2016) 1932–1938

Table 1
Measurements made from CT scans to potentially scale the structures comprising essential medical coverage.

Serial Description
A Vertical distance between horizontal planes taken at most superior and inferior levels of spleen (ie spleen height).
B Vertical distance between horizontal planes taken at most superior and inferior levels of liver (ie liver height).
C Vertical distance between horizontal planes taken at most superior and inferior points of aortic arch and liver respectively.
D Vertical distance between horizontal planes taken at most superior point of aortic arch and bifurcation of abdominal aorta.
E Vertical distance between suprasternal notch to horizontal plane taken at lowest point on ribcage in mid clavicular plane.
F Vertical distance between horizontal planes taken at lowest point on ribcage in mid clavicular plane and upper border of iliac crest
G Vertical distance between horizontal planes taken at suprasternal notch and upper border of iliac crest.
H Horizontal distance between vertical planes taken at most lateral points of liver and spleen
I Horizontal distance between vertical planes taken at right heart border and left heart border (ie heart width)
J Horizontal distance between vertical planes taken at right heart border and midline
K Horizontal distance between vertical planes taken at left heart border and midline
L Vertical distance between horizontal planes taken at suprasternal notch and upper border of liver
M Vertical distance between horizontal planes taken at upper border of liver and lower border of ribcage
N Vertical distance between horizontal planes taken at vertex of scalp and sole of feet (ie stature)

Table 2
Percentile ranges of statures derived from QinetiQ anthropometric survey in 2007 compared to those from this study (height measured by nurse on admission).

Percentile Army and marine Caucasian males only (QinetiQ survey) mm Caucasian males only (this study) mm (Distance L)
5th 1680 1700
25th 1734 1750
50th 1777 1790
75th 1822 1823
95th 1889 1900

Table 3
The distances between structures measured from the 100 CT scans in this study arranged into percentiles. Each measurement is arranged into percentiles and means
independently, not grouped on percentiles for a fixed measure.

Size grouping Soft tissue measurements Hard tissue measurements

A B C D H I J K L M E F G
5th percentile 59 125 234 315 246 111 30 72 99 144 266 40 342
25th percentile 85 147 256 336 257 123 35 83 116 160 285 57 358
50th percentile (Median) 99 161 279 353 268 130 41 91 127 174 300 71 371
75th percentile 109 173 297 370 278 139 45 99 137 186 314 88 385
95th percentile 124 189 318 393 294 150 50 111 156 207 336 106 411
Mean 98 161 277 353 269 131 40 91 124 176 300 72 373

component (Distance H) could be valid; for example basing it on

the value for the 95th percentile in this population (294 mm) Discussion
would theoretically overprotect the 5th percentile (246 mm) by
48 mm. Relating essential medical coverage to total height and torso height

Currently all UK Armed Forces personnel are provided with a

single size of front and rear ceramic body armour plate regardless
of that individual's body dimensions. The plate is enclosed within
Table 4 the carrier of the body armour vest that is usually fitted to an
Reproducibility of bone landmarks to determine the boundaries of underling soft individual’s total height. The UK VIRTUS personal armour system is
tissue structures (cross reference with Fig. 6). an important improvement from previous systems in that the
Bone versus soft tissue landmarks Mean (mm) Range (mm)
armour fitting is based on torso height instead of total height
(stature). The definition of torso height with respect to VIRTUS is
Distance suprasternal notch is above aortic arch (i) 9 20 to +27
Distance rib cage is below lower border of liver (ii) 14 47 to + 50
suprasternal notch to umbilicus (belly button). However the
Distance iliac crest is below aortic bifurcation (iii) 11 18 to + 43 umbilicus is a soft tissue landmark and will change in position with
weight gain or loss. The iliac crest is a stable bone landmark and
should be used preferentially. As essential medical coverage

Table 5
Correlation (R2) of distances between anthropometric distances and components of essential medical coverage.

Coverage Correlation with total height (N) Correlation with torso height (G)
Vertical essential medical coverage (D) R2 = 0.041 R2 = 0.531
Upper horizontal essential medical coverage (I) R2 = 0.022 R2 = 0.039
Lower horizontal essential medical coverage (H) R2 = 0.009 R2 = 0.032
 J. Breeze et al. / Injury, Int. J. Care Injured 47 (2016) 1932–1938
demonstrated the best correlation to torso height, it is therefore
recommended that torso height is used in future anthropometric
surveys and for coverage assessments.
Use of surface bone landmarks to determine the boundaries of
essential medical coverage
Accurate scaling and sizing of plates on a user requires surface
bone landmarks which can be related to the positions of the
underlying structures requiring coverage (Fig. 6). This study
suggests that from horizontal angles the upper border of essential
medical coverage is level with the suprasternal notch (landmark 1),
as it was located a mean of 9 mm above the aortic arch (the upper
border of essential medical coverage). The lower border of
essential medical coverage should be level with the upper border
of the iliac crest (landmark 3), which was located a mean of 11 mm
below the bifurcation of the aorta. Torso height (distance G) will be
larger than vertical essential medical coverage in 89% of the
population, and therefore using torso height should improve the
confidence in providing adequate protection.
Potential coverage shapes
In order to visualise the potential plate size and shape required
to provide essential medical coverage (heart, great vessels, liver
and spleen), these structures have been identified within an
anatomical model. When the boundaries were defined within this
model, essential medical coverage from front and rear horizontal
angles would require a cross-shape (Fig. 7a). The upper coverage
width is linked to heart diameter in the coronal plane; however
this showed the greatest variation between subjects and it is the
anatomical structure with greatest mortality [28]. Hence increas-
ing the upper coverage width (eg utilising values for the 95th
percentile) would increase the confidence in its medical effective-
ness (Fig. 7b). The lower section of the coverage in Fig. 7a and b is
clearly visually different from existing and traditional hard armour
(Fig. 1); but the ergonomic necessities for movements such as
bending or sitting preclude complete coverage of the lower parts of
the great vessels by hard armour. To enable maximal coverage to
the abdominal aorta, human factors assessments should be
undertaken to establish the extent to which this area can be
protected while still allowing acceptable movement (Fig. 7c).
Fig. 7. Potential coverage shapes related to bone anthropometric landmarks using the geometric representation; a) 1 = essential medical coverage, b) 2 = increased upper plate
width, c) 3 = sequentially reduced coverage height and demonstrating how edges could be rounded.
1937
Further it is recommended that coverage should not be reduced
further than the lower border of the ribcage in the mid clavicular
plane. The use of this bone landmark instead of just the lower
border of the liver was particularly important as the position of the
lower border of the liver was variable within the population
sampled. The shape of the resultant plate will be determined not
only by anatomical coverage but also by ergonomic acceptability.
This may potentially therefore result in different shapes for the
front and rear plates as is the case with the current OSPREY plates.
Limitations
There are limitations in this initial study. The structures
determined as requiring essential medical coverage are based
upon the assumption of 60 min to definitive medical care and if
that timeline changes this may necessitate review of those
structures. The sample size of 120 subjects was limited by the
number of available CT scans. The CT scans of male Caucasians were
analysed to maximise the sample size and therefore the results are
not necessarily applicable to other populations (i.e. non-Cauca-
sians and females). The measurement of internal anatomical
structures while the patient is supine (lying flat) could cause small
differences in the position of internal structures compared to a
standing subject; this will be a limitation for the foreseeable future
as imaging currently available (CT or MR) that can make such
measurements can be performed whilst standing is extremely
limited. Again the use of bone landmarks as proxy markers for the
boundaries of these soft tissue structures should overcome this
limitation. Finally this study only considered coverage from front
and rear projections; consideration also needs to be given to the
protection required from other angles (i.e. from either side of the
body) and elevations (i.e. not horizontal trajectories), along with
human factors constraints as mentioned previously.
Recommendations
A number of recommendations can be made from this study.
There was strong evidence to suggest that in future, ‘torso height’
(i.e. suprasternal notch to iliac crest) should be used as a basis for
determining armour coverage as well as correctly fitting such
armour to an individual. The acceptable size of front and rear body
armour plates that provide the recommended area of anatomical
1938 J. Breeze et al. / Injury, Int. J. Care Injured 47 (2016) 1932–1938
coverage should be identified through the construction of
prototypes of various sizes and perform ergonomic acceptability
assessments with representative military tasks until the limit of
acceptability is achieved. Alternative methods (other than a hard
body armour plate) of providing essential medical coverage against
high velocity projectiles should be investigated, especially to cover
the aorta below the diaphragm as this has the potential to increase
ergonomic acceptability.
Coverage assessments as those described herein should be
undertaken for protection to the sides of an individual and should
also consider female and non-Caucasian populations. An anthro-
pometric survey of UK Armed Forces personnel has been instigated
and will utilise the three bone landmarks identified in this study.
This will provide a torso height measurement based on a large
population and thereby enable recommendations on sizing of
plates. Further research is required to ascertain how the
dimensions of the internal anatomical structures that provide
essential medical coverage differ with subjects in different
postures such as sitting.
Conclusions
This study demonstrates that the technique of analysing CT
scans to determine dimensions for coverage is effective. By
utilising three dimensional surface scanning of individuals and a
range of bone landmarks to determine how coverage dimensions
vary in the wider population it will be possible to size a new
military recruit on joining the Armed Forces and provide them
with the most appropriately sized personal armour and clothing. In
the interim the use of the bone landmarks recommended in this
study is a step closer in enabling the correct fitting and positioning
of personal armour. The combination of positioning and fitting will
optimise the medical coverage and serve to ultimately improve
survivability.
Conflict of interest
We the authors are all members of the Ministry of Defence and
can confirm that there are no potential conflicts of interest in the
submission of this work. Permission to publish has been obtained
from the Ministry of Defence as well as the Defence Science and
Technology Laboratory on behalf of the Controller of HMSO.
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