Surgery under fire: war injuries and the consequences of delayed care in Ethiopia's Tigray region

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'ele, Ethiopia, with a particular focus on delayed surgical care, peripheral nerve injuries, and reconstructive needs.

This retrospective observational study was conducted between September and December 2023 at Ayder Comprehensive Specialized Hospital in Mek'ele, the capital city of Ethiopia's 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's exact tests, and logistic regression models were used to estimate relative likelihoods. Statistical significance was set at p < 0.05.

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.

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.