{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T11:39:42Z","timestamp":1792582782909,"version":"4.5.0"},"reference-count":41,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T00:00:00Z","timestamp":1792540800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T00:00:00Z","timestamp":1792540800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Confl Health"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>The armed conflict in Ethiopia, particularly in the Tigray region, has caused a substantial burden of war-related injuries in the context of a fragile and disrupted health system. Restricted access to timely surgical care has resulted in delayed presentation and may contribute to secondary complications, contractures, peripheral nerve dysfunction, and long-term disability. However, the consequences of delayed surgical treatment for conflict-related extremity trauma in active war settings remain insufficiently described. This study aimed to characterize conflict-related injuries in Mek\u2019ele, Ethiopia, with a particular focus on delayed surgical care, peripheral nerve injuries, and reconstructive needs.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      This retrospective observational study was conducted between September and December 2023 at Ayder Comprehensive Specialized Hospital in Mek\u2019ele, the capital city of Ethiopia\u2019s Tigray region. Patients presenting with conflict-related injuries were identified through routine clinical documentation. Epidemiological characteristics, prior surgical interventions, presenting complaints, clinical findings, and diagnoses were recorded. Peripheral nerve injuries and reconstructive challenges were analyzed in detail. Surgical treatment plans were categorized into reconstructive, corrective and functional, tendon and muscle, nerve, scar and contracture, limb or tissue removal, and supportive procedures. Group comparisons were performed using chi-square and Fisher\u2019s exact tests, and logistic regression models were used to estimate relative likelihoods. Statistical significance was set at\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.05.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>A total of 197 conflict-related injuries were analyzed, including 108 bullet injuries (54.8%) and 82 blast injuries (41.6%). Peripheral nerve injuries were identified in 54.3% of patients. Bullet injuries were more strongly associated with movement restriction, functional deficits, and peripheral nerve damage, whereas blast injuries were more frequently linked to fractures, soft tissue defects, pain, and scars or wounds. Blast injuries more often required reconstructive procedures and contracture release, while bullet injuries more frequently required corrective and functional surgery. Because most patients presented months to years after injury, primary nerve repair was rarely feasible, resulting in a high demand for secondary salvage procedures such as tendon transfers and muscle transpositions.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Conflict-related extremity trauma in Tigray is characterized not only by injury mechanism but also by the consequences of delayed access to surgical care. Missed opportunities for early definitive treatment contributed to a high burden of peripheral nerve deficits, contractures, reconstructive needs, and long-term functional impairment. Improving access to acute trauma care, early nerve repair, reconstructive surgery, and rehabilitation is essential to reduce disability in conflict-affected settings.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s13031-026-00853-7","type":"journal-article","created":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T07:43:28Z","timestamp":1792568608000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Surgery under fire: war injuries and the consequences of delayed care in Ethiopia\u2019s Tigray region"],"prefix":"10.1186","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6080-6722","authenticated-orcid":false,"given":"Anne","family":"Klausing","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Walter","family":"Bruchhausen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jan","family":"Wynands","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,10,21]]},"reference":[{"key":"853_CR1","unstructured":"Heidelberg Institute for International Conflict Research (HIIK). Conflict Barometer 2023 [2024] [Available from: https:\/\/hiik.de\/conflict-barometer\/current-version\/?lang=en. Accessed: 03.02.2025]."},{"issue":"1","key":"853_CR2","doi-asserted-by":"publisher","first-page":"76","DOI":"10.4103\/jmms.jmms_44_19","volume":"24","author":"P Sharma","year":"2022","unstructured":"Sharma P, Sharma A, Rao KR. The Changing Paradigm of Injuries and their Outcome in an International Conflict Zone. J Mar Med Soc. 2022;24(1):76\u20139.","journal-title":"J Mar Med Soc"},{"issue":"3","key":"853_CR3","doi-asserted-by":"publisher","first-page":"515","DOI":"10.1097\/00005373-200009000-00021","volume":"49","author":"RL Mabry","year":"2000","unstructured":"Mabry RL, Holcomb JB, Baker AM, Cloonan CC, Uhorchak JM, Perkins DE, et al. United States Army Rangers in Somalia: an analysis of combat casualties on an urban battlefield. J Trauma. 2000;49(3):515\u201328. discussion 28\u2009\u2013\u20099.","journal-title":"J Trauma"},{"issue":"3","key":"853_CR4","doi-asserted-by":"publisher","first-page":"311","DOI":"10.1097\/01.sla.0000114012.84732.be","volume":"239","author":"K Peleg","year":"2004","unstructured":"Peleg K, Aharonson-Daniel L, Stein M, Michaelson M, Kluger Y, Simon D, et al. Gunshot and explosion injuries: characteristics, outcomes, and implications for care of terror-related injuries in Israel. Ann Surg. 2004;239(3):311\u20138.","journal-title":"Ann Surg"},{"issue":"12","key":"853_CR5","doi-asserted-by":"publisher","first-page":"2127","DOI":"10.1089\/neu.2009.0885","volume":"26","author":"TL Benzinger","year":"2009","unstructured":"Benzinger TL, Brody D, Cardin S, Curley KC, Mintun MA, Mun SK, et al. Blast-related brain injury: imaging for clinical and research applications: report of the 2008 st. Louis workshop. J Neurotrauma. 2009;26(12):2127\u201344.","journal-title":"J Neurotrauma"},{"issue":"5","key":"853_CR6","first-page":"1468","volume":"66","author":"HR Champion","year":"2009","unstructured":"Champion HR, Holcomb JB, Young LA. Injuries from explosions: physics, biophysics, pathology, and required research focus. J Trauma. 2009;66(5):1468\u201377. discussion 77.","journal-title":"J Trauma"},{"issue":"11","key":"853_CR7","doi-asserted-by":"publisher","first-page":"2635","DOI":"10.1007\/s00268-023-07132-z","volume":"47","author":"J Dilday","year":"2023","unstructured":"Dilday J, Owattanapanich N, Benjamin ER, Biswas S, Shackelford S, Demetriades D. Injury Patterns and Treatment Strategies in Civilian and Military Isolated Abdominal Gunshot Wounds. World J Surg. 2023;47(11):2635\u201343.","journal-title":"World J Surg"},{"issue":"4","key":"853_CR8","doi-asserted-by":"publisher","first-page":"e5753","DOI":"10.1097\/GOX.0000000000005753","volume":"12","author":"TE Muss","year":"2024","unstructured":"Muss TE, Hu S, Bauder AR, Lin IC. The Epidemiology, Management, and Outcomes of Civilian Gunshot Wounds to the Upper Extremity at an Urban Trauma Center. Plast Reconstr Surg Glob Open. 2024;12(4):e5753.","journal-title":"Plast Reconstr Surg Glob Open"},{"issue":"13","key":"853_CR9","doi-asserted-by":"publisher","first-page":"1335","DOI":"10.1056\/NEJMra042083","volume":"352","author":"RG DePalma","year":"2005","unstructured":"DePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast injuries. N Engl J Med. 2005;352(13):1335\u201342.","journal-title":"N Engl J Med"},{"issue":"3","key":"853_CR10","first-page":"148","volume":"15","author":"S Luria","year":"2013","unstructured":"Luria S, Rivkin G, Avitzour M, Liebergall M, Mintz Y, Mosheiff R. Comparative outcome of bomb explosion injuries versus high-powered gunshot injuries of the upper extremity in a civilian setting. Isr Med Assoc J. 2013;15(3):148\u201352.","journal-title":"Isr Med Assoc J"},{"issue":"1","key":"853_CR11","doi-asserted-by":"publisher","first-page":"352","DOI":"10.1186\/s13104-023-06640-4","volume":"16","author":"AA Asgedom","year":"2023","unstructured":"Asgedom AA, Etsedingl A, Hailemariam TT, Tequare MH, Hailu T, Tsegay AT, et al. Prevalence, causes and outcomes of war-related civilian injuries in Ethiopia\u2019s war-torn Tigray region: a community-based descriptive study. BMC Res Notes. 2023;16(1):352.","journal-title":"BMC Res Notes"},{"key":"853_CR12","unstructured":"World Health Organization (WHO). Building peace in fragile and conflict settings through health [2024] [Available from: https:\/\/www.who.int\/activities\/building-peace-in-fragile-and-conflict-settings-through-health. Accessed: 17.02.2025]."},{"issue":"7333","key":"853_CR13","doi-asserted-by":"publisher","first-page":"346","DOI":"10.1136\/bmj.324.7333.346","volume":"324","author":"CJ Murray","year":"2002","unstructured":"Murray CJ, King G, Lopez AD, Tomijima N, Krug EG. Armed conflict as a public health problem. BMJ. 2002;324(7333):346\u20139.","journal-title":"BMJ"},{"key":"853_CR14","unstructured":"Grasa R, Mateos O, Conflict. Peace and Security in Africa: An Assessment and New Questions after 50 Years of African Independence [2010] [Available from: https:\/\/ssrn.com\/abstract=1884194. Accessed: 17.02.2025]."},{"issue":"5","key":"853_CR15","first-page":"279","volume":"23","author":"SD Iordache","year":"2021","unstructured":"Iordache SD, Gorski A, Nahas M, Feintuch L, Rahamimov N, Frenkel Rutenberg T. Treatment of Peripheral Nerve Injuries in Syria\u2019s War Victims: Experience from a Northern Israeli Hospital. Isr Med Assoc J. 2021;23(5):279\u201385.","journal-title":"Isr Med Assoc J"},{"issue":"5","key":"853_CR16","doi-asserted-by":"publisher","first-page":"e3570","DOI":"10.1097\/GOX.0000000000003570","volume":"9","author":"JM Felder","year":"2021","unstructured":"Felder JM, Ducic I. Chronic Nerve Injuries and Delays in Surgical Treatment Negatively Impact Patient-reported Quality of Life. Plast Reconstr Surg Glob Open. 2021;9(5):e3570.","journal-title":"Plast Reconstr Surg Glob Open"},{"key":"853_CR17","unstructured":"Statista. Median age in Africa 2000\u20132030. 2024."},{"key":"853_CR18","doi-asserted-by":"publisher","first-page":"11","DOI":"10.1186\/1472-698X-13-11","volume":"13","author":"CW Kabiru","year":"2013","unstructured":"Kabiru CW, Izugbara CO, Beguy D. The health and wellbeing of young people in sub-Saharan Africa: an under-researched area? BMC Int Health Hum Rights. 2013;13:11.","journal-title":"BMC Int Health Hum Rights"},{"issue":"1","key":"853_CR19","doi-asserted-by":"publisher","first-page":"44","DOI":"10.1186\/s13018-023-03527-9","volume":"18","author":"AY Mohamed","year":"2023","unstructured":"Mohamed AY, Ibrahim HS, Taskoparan H, Ibrahim YB. Epidemiological characteristics and comparative outcome of blast versus gunshot injuries of the extremities in Somalia. J Orthop Surg Res. 2023;18(1):44.","journal-title":"J Orthop Surg Res"},{"key":"853_CR20","unstructured":"Human Sciences Research Council (HSRC). Young Men and the Construction of Masculinity in Sub-Saharan Africa: Implications for Participation in Violence. Human Sciences Research Council (HSRC); 2006."},{"key":"853_CR21","unstructured":"Amnesty International. Sub-Saharan Africa: The Devastating Impact of Conflicts Compounded. 2021."},{"key":"853_CR22","doi-asserted-by":"publisher","unstructured":"Dorward N. The urbanization of conflict? Patterns of armed conflict and protest in Africa. Afr Affairs. 2024;123(493):468\u201301. https:\/\/doi.org\/10.1093\/afraf\/adae025.","DOI":"10.1093\/afraf\/adae025"},{"issue":"1","key":"853_CR23","doi-asserted-by":"publisher","first-page":"125","DOI":"10.1186\/s13049-024-01299-7","volume":"32","author":"K Chevalley","year":"2024","unstructured":"Chevalley K, Zimmerman J, Mittendorf A, Sennersten F, Dalman A, Frogh S, et al. Civilian pattern of injuries in armed conflicts - a systematic review. Scand J Trauma Resusc Emerg Med. 2024;32(1):125.","journal-title":"Scand J Trauma Resusc Emerg Med"},{"key":"853_CR24","doi-asserted-by":"publisher","first-page":"101676","DOI":"10.1016\/j.eclinm.2022.101676","volume":"54","author":"L Maitland","year":"2022","unstructured":"Maitland L, Middleton L, Veen H, Harrison DJ, Baden J, Hettiaratchy S. Analysis of 983 civilian blast and ballistic casualties and the generation of a template of injury burden: An observational study. EClinicalMedicine. 2022;54:101676.","journal-title":"EClinicalMedicine"},{"key":"853_CR25","doi-asserted-by":"publisher","first-page":"133","DOI":"10.11604\/pamj.2022.43.133.31587","volume":"43","author":"DO Odatuwa-Omagbemi","year":"2022","unstructured":"Odatuwa-Omagbemi DO, Otene CI, Enemudo RET, Imonijevwe ES, Sefia TE. Gunshot injuries: experience in a tertiary health facility in the Niger Delta Region of Nigeria. Pan Afr Med J. 2022;43:133.","journal-title":"Pan Afr Med J"},{"key":"853_CR26","doi-asserted-by":"crossref","unstructured":"Kelly JF, Ritenour AE, McLaughlin DF, Bagg KA, Apodaca AN, Mallak CT, et al. Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003\u20132004 versus 2006. J Trauma. 2008;64(2 Suppl):S21-6(discussion S 26-27).","DOI":"10.1097\/TA.0b013e318160b9fb"},{"issue":"58","key":"853_CR27","doi-asserted-by":"publisher","first-page":"689","DOI":"10.1098\/rsif.2010.0476","volume":"8","author":"A Ramasamy","year":"2011","unstructured":"Ramasamy A, Hill AM, Masouros S, Gibb I, Bull AM, Clasper JC. Blast-related fracture patterns: a forensic biomechanical approach. J R Soc Interface. 2011;8(58):689\u201398.","journal-title":"J R Soc Interface"},{"key":"853_CR28","doi-asserted-by":"publisher","first-page":"01","DOI":"10.47829\/COS.2024.101001","volume":"10","author":"NDM Mokake","year":"2024","unstructured":"Mokake NDM, Atabong BM, Ekani EM, Yawa N, Nana N, Theophile N, et al. Clinical Characteristics, Treatment and Outcome of Gunshot Injuries in South West Region of Cameroon. Clin Surg. 2024;10:01\u201310.","journal-title":"Clin Surg"},{"issue":"2 Suppl 1","key":"853_CR29","doi-asserted-by":"publisher","first-page":"S32","DOI":"10.1097\/TA.0b013e3182606001","volume":"73","author":"RL Mabry","year":"2012","unstructured":"Mabry RL, Apodaca A, Penrod J, Orman JA, Gerhardt RT, Dorlac WC. Impact of critical care-trained flight paramedics on casualty survival during helicopter evacuation in the current war in Afghanistan. J Trauma Acute Care Surg. 2012;73(2 Suppl 1):S32\u20137.","journal-title":"J Trauma Acute Care Surg"},{"key":"853_CR30","doi-asserted-by":"publisher","unstructured":"Alsalqawi A, Villar R. Patterns of Injury in a Gaza War Hospital. medRxiv [Prepring]. 2024. https:\/\/doi.org\/10.1101\/2024.06.27.24309570.","DOI":"10.1101\/2024.06.27.24309570"},{"key":"#cr-split#-853_CR31.1","unstructured":"UN Women. War on women: proportion of women killed in armed conflicts doubles in 2023. New York: UN Women"},{"key":"#cr-split#-853_CR31.2","unstructured":"2024 Oct 22 [cited 2026 Apr 17]. Available from: https:\/\/www.unwomen.org\/en\/news-stories\/press-release\/2024\/10\/war-on-women-women-killed-in-armed-conflicts-double-in-2023."},{"key":"853_CR32","first-page":"12","volume":"4","author":"F Schneider","year":"2016","unstructured":"Schneider F, Neidhardt M. Besonderheiten und Versorgung penetrierender Verletzungen am Beispiel von Schuss- und Explosionsopfern ohne ballistischen K\u00f6rperschutz in Afghanistan (2009\u20132013). Wehrmedizin und Wehrpharmazie. 2016;4:12\u20137.","journal-title":"Wehrmedizin und Wehrpharmazie"},{"issue":"10","key":"853_CR33","doi-asserted-by":"publisher","first-page":"3019","DOI":"10.1007\/s00268-021-06242-w","volume":"45","author":"MK Moustafa","year":"2021","unstructured":"Moustafa MK, Al-Hajj S, El-Hechi M, El Moheb M, Chamseddine Z, Kaafarani HMA. The Burden of Surgical Disease and Access to Care in a Vulnerable Syrian Refugee Population in Lebanon. World J Surg. 2021;45(10):3019\u201326.","journal-title":"World J Surg"},{"issue":"3","key":"853_CR34","doi-asserted-by":"publisher","first-page":"656","DOI":"10.1007\/s00268-019-05239-w","volume":"44","author":"ER Smith","year":"2020","unstructured":"Smith ER, Concepcion TL, Shrime M, Niemeier K, Mohamed M, Dahir S, et al. Waiting Too Long: The Contribution of Delayed Surgical Access to Pediatric Disease Burden in Somaliland. World J Surg. 2020;44(3):656\u201364.","journal-title":"World J Surg"},{"issue":"2","key":"853_CR35","doi-asserted-by":"publisher","first-page":"189","DOI":"10.1007\/s43465-022-00791-5","volume":"57","author":"J Braga Silva","year":"2023","unstructured":"Braga Silva J, Becker AS, Leal BLM, Busnello CV. Advances of Direct Peripheral Nerve Repair Techniques: Do We Already Have Enough Scientific Evidence? Indian J Orthop. 2023;57(2):189\u2013202.","journal-title":"Indian J Orthop"},{"key":"853_CR36","doi-asserted-by":"publisher","first-page":"510","DOI":"10.3171\/jns.1945.2.6.0510","volume":"2","author":"HG Schwartz","year":"1945","unstructured":"Schwartz HG, Parker JM. Early nerve and bone repair in war wounds. J Neurosurg. 1945;2:510\u20135.","journal-title":"J Neurosurg"},{"issue":"1","key":"853_CR37","first-page":"1","volume":"29","author":"OO Ogwumike","year":"2014","unstructured":"Ogwumike OO, Adeniyi AF, Badaru U, Onimisi JO. Profile of children with new-born brachial plexus palsy managed in a tertiary hospital in Ibadan, Nigeria. Niger J Physiol Sci. 2014;29(1):1\u20135.","journal-title":"Niger J Physiol Sci"},{"key":"853_CR38","doi-asserted-by":"publisher","first-page":"e62","DOI":"10.1016\/j.wneu.2022.11.136","volume":"172","author":"S Nguembu","year":"2023","unstructured":"Nguembu S, Kenfack YJ, Sadler S, Zolo Y, Figuim B, Sebopelo LA, et al. Factors Associated with Adverse Outcomes in Cameroonian Patients with Traumatic Brain Injury: A Cross-Sectional Study. World Neurosurg. 2023;172:e62\u20137.","journal-title":"World Neurosurg"},{"key":"853_CR39","unstructured":"Naqvi U, Sherman AL. Muscle Strength Grading. StatPearls. Treasure Island (FL) ineligible companies. Disclosure: Andrew Sherman declares no relevant financial relationships with ineligible companies.2025."},{"key":"853_CR40","unstructured":"Medical Research Council. MRC Muscle Scale United Kingdom. UK Research and Innovation (UKRI); [2023] [updated 2023. Available from: https:\/\/www.ukri.org\/councils\/mrc\/facilities-and-resources\/find-an-mrc-facility-or-resource\/mrc-muscle-scale\/. Accessed: 12.02.2025]."}],"container-title":["Conflict and Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s13031-026-00853-7","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s13031-026-00853-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s13031-026-00853-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T10:46:40Z","timestamp":1792579600000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s13031-026-00853-7"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,21]]},"references-count":41,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["853"],"URL":"https:\/\/doi.org\/10.1186\/s13031-026-00853-7","relation":{},"ISSN":["1752-1505"],"issn-type":[{"value":"1752-1505","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,21]]},"assertion":[{"value":"27 April 2026","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"13 October 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"21 October 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"This study was based on a retrospective analysis of routinely collected clinical data from patients treated at Ayder Comprehensive Specialized Hospital in Mek\u2019ele, Ethiopia. Routine clinical records were anonymised before transfer into the analytical dataset, and no directly identifiable personal information was included. The Ethics Committee of the Medical Faculty, University of Bonn reviewed the study protocol and issued a waiver confirming that the retrospective analysis of anonymised routine clinical data did not require full ethical consultation under local regulations (Ethics Reference No. 2026\u2009\u2212\u2009469). The study was conducted in accordance with the principles of the Declaration of Helsinki.","order":1,"name":"Ethics","label":"Ethics approval and consent to participate","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable.","order":2,"name":"Ethics","label":"Consent for publication","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare no competing interests.","order":3,"name":"Ethics","label":"Competing interests","group":{"name":"EthicsHeading","label":"Declarations"}}],"article-number":"84"}}