Orthopedic War-Related Injuries in Gaza: In-Depth Insights from within the Strip
##plugins.themes.bootstrap3.article.main##
Gaza has been under continuous attack for over a year, resulting in widespread destruction and a severe humanitarian crisis. The bombings have caused mass casualties and devastating injuries, with buildings collapsing and overwhelming the healthcare system. Attacks on hospitals, arrests of medical staff, and severe shortages of medical supplies have hindered the delivery of life-saving treatments, forcing hospitals to provide only basic care. Due to a lack of specialized staff and equipment, treatment delays and infection risks have increased, and emergency measures such as amputations are often used. This review highlights the critical medical situation in Gaza, focusing on the challenges faced by medical staff, the impact of war-related injuries, and the broader health consequences caused by infrastructure damage and limited access to healthcare.
Downloads
Introduction
War injuries encompass a wide range of severe traumas, including bullet wounds, burns, and amputations from explosions, often leading to complex head, chest, and abdominal injuries, comminuted fractures, soft tissue loss, nerve damage, and blood vessel injuries. These injuries are further complicated by burns, chemical exposure, and contamination, making both immediate and long-term treatment challenging, especially when care is delayed [1], [2]. Major war injuries include gunshot wounds, which damage tissue through impact, cavitation, and contamination, with severity varying by energy transfer and bullet type, and blast injuries, caused by explosive forces that can harm multiple body areas. Blast injuries are categorized as primary (affecting air-filled organs), secondary (from flying fragments), tertiary (from body displacement), and quaternary (from structural collapse). Modern munitions amplify the impact of these injuries by increasing fragment spread, heightening injury severity and reach [3], [4].
However, the impact of war on health is not limited to direct physical injuries. Conflict environments frequently disrupt healthcare systems, leading to a secondary health crisis. Restricted access to medical facilities, destruction of infrastructure, and interrupted services such as vaccination programs contribute to increased mortality from communicable and non-communicable diseases, maternal and neonatal health complications, nutritional deficiencies, and other non-combat-related health issues. Consequently, war becomes a multifaceted health crisis, where the scope and severity of indirect impacts often rival those of the direct injuries, highlighting the extensive toll of conflict on affected populations [5]–[7].
For over a year, Gaza has faced ongoing attacks from Israel, leading to widespread devastation and a severe humanitarian crisis. Various weapons have been deployed in these attacks, resulting in tragic massacres and mass casualties, as buildings are bombarded and collapse with people inside, leading to catastrophic injuries. The medical situation in Gaza is exacerbated by attacks on hospitals, the arrest of medical staff, and severe restrictions on medical supplies, Figs. 1 and 2. These actions critically hinder the ability to deliver life-saving treatments, leaving remaining hospitals able to provide only the most basic care for severe injuries [8].
Fig. 1. A photograph of Al Shifa Hospital’s surgery wing (the largest hospital in the Gaza Strip), taken on Monday, April 1, 2024, captures the aftermath following the withdrawal of Israeli forces from the compound [9].
Fig. 2. (A) Doctors provide first aid to Palestinians at Al-Aqsa Martyrs Hospital in Deir el-Balah, Gaza, following an Israeli attack on January 6, 2024 [10]. (B) Patients lie on the floor as hospitals, under immense pressure, are unable to accommodate the growing number of casualties, with many facilities no longer operational [11].
This review aims to shed light on the critical medical situation in Gaza due to the ongoing war, focusing on the scope and complexity of war-related injuries. By providing an overview of injuries, highlighting key facts, and presenting case examples, the review seeks to emphasize the challenges faced by medical staff, the constraints on healthcare delivery, and the extensive physical and psychological impact on injured civilians. This analysis examines both the direct effects of war injuries and the indirect health consequences caused by restricted healthcare access, infrastructure damage, and shortages of medical team and supplies.
This review highlights the extensive challenges facing Gaza’s healthcare system and its patients due to the ongoing conflict. It details the limitations and barriers to delivering comprehensive care from preoperative to postoperative stages.
Preoperative Medical Condition
Due to mass-casualty incidents and limited medical supplies and staff, many patients receive only initial primary care focused on stabilizing life-threatening injuries and immobilizing fractures, often using external fixators or casting for bone stabilization. However, this primary treatment frequently does not fully address associated soft tissue injuries, such as tendon and nerve damage. Consequently, patients may experience prolonged delays before receiving definitive surgical interventions, leading to complications such as contractures, superimposed infections, and joint stiffness.
Due to restricted food supplies, many patients are malnourished and anemic, with hemoglobin levels averaging around 10–12 mg/dL. This impacts healing, worsens intraoperative blood loss, and may delay postoperative recovery.
In addition, these patients often present with complex skin conditions from prior treatments. Skin grafts and muscle flaps add significant challenges for surgical planning. Persistent pin-site infections from external fixators are also common, heightening the risk of infection spread and further complicating preoperative status.
Hygiene is another critical issue, as limited water resources make it challenging for patients to maintain basic cleanliness, which heightens their risk of infection. This lack of proper hygiene, coupled with inadequate wound care supplies, further escalates the likelihood of surgical-site infections.
The psychological impact of war also cannot be overlooked. Many patients have lost family members, homes, and entire communities, which severely affects their mental health and resilience. Post-traumatic stress, anxiety, and depression are prevalent, negatively impacting patient engagement in rehabilitation and overall healing. This combination of physical and psychological trauma poses substantial obstacles to the successful management of preoperative and postoperative care in these patients.
The shortage of caregivers in homes and camps due to family losses, injuries, and frequent displacement severely limits preoperative and postoperative care. Many patients struggle to access medical assistance or transport to healthcare facilities due to ongoing conflict, blockade, and infrastructure damage. This lack of support prevents timely medical care and hinders recovery and ongoing treatment, worsening health vulnerabilities.
Spectrum of Injuries
The diverse array of weaponry used in the conflict has resulted in a broad spectrum of injuries among Gaza’s civilian population. These injuries include mechanical, chemical, and thermal trauma, as well as contamination from various sources and severe burn injuries. The mechanisms of injury are often complex and overlapping, involving both primary impacts from explosions and secondary impacts from shrapnel and debris.
Bone fractures and bone loss are particularly common, frequently accompanied by extensive soft tissue injuries (see Figs. 3 and 4). These soft tissue injuries include significant skin loss, extensive muscle damage, nerve injuries, and vascular damage. The combination of bone and soft tissue trauma results in complex, multi-layered injuries that impact entire body regions and often require extensive intervention.
Fig. 3. Spectrum of upper limb injuries showing severe cases with bone comminution and loss. (A) Elbow injury in a 19-year-old male, with loss of distal humerus and proximal ulna, indicating severe soft tissue damage. (B) Open left humerus fracture from shrapnel, with remaining fragments, in a 21-year-old male. (C) Loss of distal radius with radial artery and soft tissue injury in a 34-year-old male. (D) Comminuted forearm fracture with shell fragment in a 43-year-old male. (E) Distal ulna bone loss in a 21-year-old male. (F) Multiple comminuted metacarpal fractures from a tank shell in a 23-year-old male.
Fig. 4. Examples of lower limb injuries. (A) Left proximal femur fracture in a 10-year-old boy, with loss of iliac bone and associated bladder injury. (B) Right femoral neck fracture from a bullet injury in a 16-year-old boy, treated with an external fixator. (C) Comminuted right distal femur fracture stabilized by an external fixator in a 29-year-old male. (D) Comminuted left distal tibia fracture stabilized by an external fixator in a 26-year-old female.
One of the primary challenges in treating these injuries is the tendency for them to heal through extensive fibrosis. This excessive scarring stiffens the surrounding tissue and entraps muscles, nerves, and blood vessels, creating dense, rigid masses that complicate any subsequent surgeries. For instance, definitive surgical treatments, such as fracture reduction and soft tissue repair, are far more challenging when surrounded by fibrotic tissue. The neurovascular structures are often caught within or around fractured bones due to the nature of blast injuries, increasing the risk of damage during surgery. Surgeons must navigate this delicate anatomy, prolonging the operative time and introducing additional risks.
Moreover, contamination from weapon residues, debris, and the challenging conditions of a conflict zone frequently result in infections that can further complicate treatment. Bacterial contamination from both the environment and from lack of immediate access to sterile conditions leads to chronic infection in many wounds. In the case of burns and chemical injuries, the skin and underlying tissues are damaged extensively, often leaving permanent scars and functional limitations that impede joint movement and muscle function.
This combination of complex injuries poses immense challenges to healthcare providers. With limited medical resources and a high volume of patients, delivering effective treatment becomes increasingly difficult, particularly as these types of injuries demand specialized care, long-term rehabilitation, and sometimes multiple reconstructive surgeries to achieve even basic functionality. The physical and psychological burden of these injuries highlights the urgent need for targeted medical, surgical, and rehabilitative support in conflict-affected populations.
Intraoperative Conditions
Due to the extensive bombing and subsequent damage to most hospitals, along with severe restrictions on medical supplies, for example orthopedic implants, the availability of optimal treatment options is highly limited. Many essential services are now provided in field hospitals that lack proper operating conditions. For instance, these temporary setups lack advanced facilities such as negative pressure systems in operating rooms, which are critical for preventing infection, and often rely on inadequate lighting, at times resorting to cell phone flashlights to complete surgeries.
The high patient volume, coupled with a significant shortage of qualified doctors, further strains the delivery of effective care. This demand has led to some surgical procedures being conducted by healthcare providers without specialized training in orthopedics, and, in some cases, even by non-surgeons. When qualified surgeons are available, the lack of appropriate operating equipment and facilities still hinders optimal management. For example, the absence of fluoroscopic imaging forces surgeons to rely on clinical judgment alone for fracture fixation, increasing the risk of misalignment or improper fixation.
In mass-casualty situations, patients have been treated on the floor, with procedures like applying external fixators and performing amputations done without anesthesia due to severe resource shortages. A lack of essential orthopedic implants and instruments forces surgeons to stabilize fractures with inappropriate implants, using either too-short or too-long plates. Complex fractures, including femoral neck fractures, are sometimes stabilized with Kirschner wires or external fixators without addressing soft tissue injuries. Additionally, basic supplies-such as gowns, gloves, sterilization solutions, and dressings-are limited, increasing infection risk for already contaminated wounds.
Amputations
Many severe limb injuries that might otherwise be treated through reconstructive surgery are instead managed by amputation. This approach is often necessary due to the resource limitations in a region overwhelmed by a large number of critically injured patients. Reconstruction requires multiple surgeries, prolonged hospital stays, and specialized postoperative care, which are challenging to provide under current conditions. Consequently, amputation has become a more feasible-albeit drastic-solution, especially in light of the overwhelming number of casualties. For example, a single attack on al-Ahli Arab hospital in northern Gaza tragically resulted in 500 deaths, underscoring the sheer scale of injuries and the limited capacity to treat each patient [12].
Hundreds of individuals with severe limb injuries have undergone amputations or received bone stabilization through external fixators, often administered by non-specialized personnel, including doctors from other medical fields and nurses. The scarcity of orthopedic specialists and trained surgical teams has necessitated the involvement of general practitioners and healthcare workers without specific orthopedic training.
In some instances, amputations have been performed without anesthesia due to limited medical supplies and an overwhelmed healthcare system. The lack of anesthesia during these traumatic procedures has contributed to a high incidence of phantom limb syndrome, where patients experience pain and sensations from the lost limb. The emotional and physical toll of such procedures is exemplified in one account of a doctor who, due to lack of medical resources, amputated his niece’s leg using a kitchen knife without anesthesia or proper sterility-a painful decision made in a desperate situation [13].
Furthermore, many amputations have been performed under suboptimal conditions, resulting in complications. Improperly executed amputations often leave patients with a short residual limb or improper bone cut that impairs prosthetic fitting and comfort. Nerves are sometimes not cut sufficiently above the amputation level, leading to painful neuromas in the stump (see Fig. 5). These issues contribute to significant postoperative challenges: many patients find their prostheses ill-fitting and uncomfortable, leading to non-compliance with prosthetic use and reducing their mobility and quality of life.
Fig. 5. Examples of amputations showing poorly organized stumps. (A) Right below-knee amputation in a 27-year-old male, with a long fibula causing discomfort with the prosthesis. (B) Left below-knee amputation with an associated comminuted femur fracture stabilized by an external fixator in a 23-year-old male; the prominent tibia at the stump makes the prosthesis painful. (C) Right above-knee amputation in a 30-year-old male with a left femoral shaft fracture fixed by an external fixator; the patient reports phantom limb pain and multiple neuromas at the amputation site. (D) Little and ring finger amputation with a prominent fifth metacarpal bone in a 54-year-old male.
The combination of physical pain, psychological trauma, and limited rehabilitation resources further complicates the recovery journey for amputees in Gaza, highlighting the urgent need for specialized surgical care, rehabilitation support, and mental health resources in conflict zones.
Post-Operative Care and Conditions
After surgery, patients require comprehensive rehabilitation and nutritional support for optimal recovery. However, due to the overwhelming number of injuries, patients are often discharged prematurely, without completing rehabilitation or antibiotic courses. They are sent to crowded tent camps with limited access to essential resources such as food, clean water, and adequate hygiene. The lack of electricity results in tents becoming very hot, which causes wounds to become sweaty and increases the risk of infection.
Damaged infrastructure, particularly sanitation systems, leads to frequent sewage overflows in tented areas, attracting mosquitoes and flies that further expose wounds to infections. This unsanitary environment hinders healing and aggravates malnourishment, as access to nutritional resources remains inadequate. Shortages of medical supplies, including antibiotics and dressings, also compromise follow-up care.
Additionally, there is a lack of basic mobility aids, like crutches and wheelchairs, which significantly challenges patients. Limited access to public bathrooms unsuitable for injured patients, with long wait times, adds further strain. Psychological trauma, including post-traumatic stress and depression, is another critical challenge, exacerbated by the lack of mental health support.
Some procedures are performed by visiting doctors on short-term missions, but these visits often lack the time needed to complete a patient’s full treatment plan. For patients requiring staged surgeries, their treatment may be interrupted as new waves of injuries overwhelm Gaza’s healthcare system. Frequent displacement further complicates consistent follow-up. Many patients need additional surgeries, such as for other limbs or complex procedures like tendon transfers, nerve surgeries, and managing injury sequences.
Armed conflicts impose severe health burdens on women and children, resulting in high morbidity and mortality through both direct violence and indirect effects, including malnutrition, infectious diseases, and poor mental and reproductive health. Women and children near conflict zones face heightened mortality risks, with infants’ death risks rising by over 25% and reproductive-age women experiencing three times higher mortality compared to peaceful areas. Conflicts worsen food insecurity, leading to chronic and acute malnutrition, while damaged water, sanitation, and healthcare services increase vulnerability to infectious diseases. The impacts on mental health are profound, particularly for post-traumatic stress disorders, depression, and anxiety. Data collection challenges in conflict zones hinder effective policy-making, underscoring the need for targeted data to address these escalating health crises [14], [15].
What is Special about Gaza?
Injuries of this severity can occur anywhere in the world, and under normal conditions, patients would receive comprehensive, multidisciplinary treatment involving orthopedic, vascular, and plastic surgery teams, alongside essential psychological support and rehabilitative care. Such an approach ensures that patients not only have their immediate injuries addressed but also receive the best possible support for recovery and functionality, with specialists focusing on intricate repairs of nerves, tendons, and muscles.
In Gaza, however, the circumstances are starkly different. Patients often receive only basic care, such as wound closure, dressing, and external fixation to stabilize fractures. In many cases, there is little to no access to advanced interventions, such as bone fixation, nerve or tendon repair, or definitive reconstructive surgeries. Consequently, patients face the harsh reality of receiving temporary or incomplete treatment, which can severely impact their recovery and long-term quality of life.
Moreover, due to the severity of injuries and limited resources amid ongoing conflict, amputation may become the only viable option, either because of the extent of the damage or the lack of advanced treatment options necessary for limb salvage. This reality leaves many individuals in Gaza with disabilities that could have been preventable if comprehensive care were accessible. The lack of specialized treatment, compounded by the war conditions, not only limits patients’ recovery but also places a tremendous strain on Gaza’s already fragile healthcare system, underscoring the urgent need for increased medical resources and support.
Injuries with bone loss and extensive soft tissue damage present significant recovery challenges, often leading to infections, muscle contractures, and fibrosis, which can severely limit mobility and increase the risk of long-term disability. Exposed bone and tissue are particularly susceptible to infection. Contractures and fibrosis further restrict joint movement, causing stiffness and impairing functionality. Without timely, advanced treatment and structured rehabilitation, these issues are compounded by delayed healing and joint immobility, complicating future interventions and reducing the likelihood of full recovery. Early, comprehensive care involving infection control, physical therapy, and reconstructive surgery is critical to improving outcomes and minimizing permanent disability, underscoring the necessity of accessible medical and rehabilitative support.
The challenges of treating war-related injuries in Gaza highlight the severe limitations and complexities faced by medical staff in an ongoing conflict. In normal settings, severe injuries would benefit from a multidisciplinary approach, including specialists in orthopedic, vascular, plastic surgery, and mental health, to address tissue damage, nerve involvement, and bone stability. However, in Gaza, the lack of specialized care, limited surgical supplies, and high patient volumes force clinicians to prioritize immediate stabilization, often neglecting more intricate treatments like nerve and tendon repairs. This results in delayed or inadequate care, leading to complications such as fibrosis, contractures, and chronic infections, which exacerbate suffering and disabilities, emphasizing the urgent need for international support to improve healthcare infrastructure.
The shortage of medical supplies, coupled with limited access to advanced care, forces many injuries to heal without proper intervention, known as “natural history” healing. This lack of early, specialized treatment complicates later medical efforts, often leading to more challenging surgical repairs, longer recovery times, and poorer overall outcomes. The combination of continuous violence and constrained medical services has created a cycle of suffering in Gaza, with injuries that could have been effectively treated becoming long-term disabilities or even resulting in preventable deaths. The need for international attention and support for Gaza’s medical infrastructure has never been more urgent, as healthcare providers face near-impossible conditions to deliver even the most basic care to those affected.
Conclusions
The ongoing warfare in Gaza has led to a severe humanitarian crisis, with civilians suffering from complex and debilitating war-related injuries. The use of modern weaponry has exacerbated the severity of injuries, often resulting in catastrophic harm from blast forces, gunshot wounds, and explosions, causing extensive physical trauma, including fractures, burns, and soft tissue loss. The healthcare system in Gaza, already overwhelmed, is under further strain due to attacks on medical institutions, shortages of medical supplies, and a lack of specialized personnel. As a result, hospitals are unable to provide comprehensive care, forcing medical teams to rely on emergency interventions, often in inadequate conditions.
Additionally, the indirect effects of the conflict, such as limited access to healthcare, damaged infrastructure, and the spread of infectious diseases, further intensify the physical burden on the population. Psychological trauma, including post-traumatic stress, anxiety, and depression, significantly impacts recovery and rehabilitation. The combination of severe physical injuries, limited medical resources, and the psychological consequences of the conflict underscores the urgent need for international support to address Gaza’s critical healthcare challenges. Long-term solutions must focus on restoring medical infrastructure, improving access to specialized care, and providing comprehensive psychological and rehabilitative support for the war-affected population.
References
-
Marshall TJJr. Combat casualty care: the alpha surgical com- pany experience during operation Iraqi freedom. Mil Med . 2005;170(6):469–72.
DOI |
Google Scholar
1
-
Ryan JM, Cooper GJ, Haywood IR, Milner SM. Surgery on a future conventional battlefield: strategy and wound management. Ann R Coll Surg Engl. 1991;73:13–20.
Google Scholar
2
-
Mannion SJ, Chaloner E. Principles of war surgery. BMJ . 2005;330(7506):1498–500.
DOI |
Google Scholar
3
-
Riddez L. Wounds of war in the civilian sector: principles of treatment and pitfalls to avoid. Eur J Trauma Emerg Surg. 2014;40(4):461–8.
DOI |
Google Scholar
4
-
Navarese EP, Grzelakowska K, Mangini F, Kubica J, Banach M, BennM, etal. The spoils of war and the long-term spoiling of health conditions of entire nations. Atherosclerosis. 2022;352:76–9.
DOI |
Google Scholar
5
-
Bürgin D, Anagnostopoulos D, Vitiello B, Sukale T, Schmid M, Fegert JM. Impact of war and forced displacement on children’s mental health. Eur Child Adolesc Psychiatry. 2022;31(6):845-53.
DOI |
Google Scholar
6
-
Marou V, Vardavas CI, Aslanoglou K, Nikitara K, Plyta Z, Leonardi-Bee J, et al. The impact of conflict on infectious disease: a systematic literature review. Confl Health. 2024;18:27.
DOI |
Google Scholar
7
-
Humanity & Inclusion. Gaza: health and rehabilitation—issue brief [Accessed 7 Jan 2025]. 2023. https://www.humanity-inclusion. org.uk/en/gaza-critical-lack-of-rehabilitation-services-for-injured- will-leave-generation-of-people-with-permanent-disabilities.
Google Scholar
8
-
Health Policy Watch. Israel withdraws from Gaza’s Al-Shifa Hospital; large portions of facility destroyed in fighting [Internet]. 2023 [cited 2024 Jan 15]. Available from: http://watch.news/ israel-withdraws-from-gazas-al-shifa-hospital-large-portions-of- facility-destroyed-in-fighting/.
Google Scholar
9
-
Jazeera Al. How doctors in Gaza persevere amid Israel attacks [Internet]. 2024 Jan 23 [cited 2024 Jan 25]. Available from: https://www.aljazeera.com/features/longform/2024/1/23/how-doc tors-in-gaza-persevere-amid-israel-attacks.
Google Scholar
10
-
Beaubien J. Inside Gaza’s hospitals as war rages: ‘We don’t have anything to help us’ [Accessed 7 Jan 2025]. New York Times. 2023 Nov 6. https://www.nytimes.com/2023/11/06/world/ middleeast/gaza-hospitals-israel-war.html.
Google Scholar
11
-
ABC News (Australia). What we know about the Al-Ahli hospital blast in Gaza [Accessed 7 Jan 2025]. 2023 Oct 18. https://www.abc. net.au/news/2023-10-18/what-we-know-about-al-ahli-hospital-blast-in-gaza/102990176.
Google Scholar
12
-
Reuters. Gaza doctor amputates niece’s leg at home, without anaesthesia. 2024 Jan 19 [cited 2024 Jan 25]. Available from: https://www.reuters.com/world/middle-east/gaza-doctor-amputates- niecse-leg-home-without-anaesthesia-2024-01-19/.
Google Scholar
13
-
Bendavid E, Boerma T, Akseer N, Langer A, Malembaka EB, Okiro EA, et al. The effects of armed conflict on the health of women and children. Lancet. 2021;397(10273):522–32.
DOI |
Google Scholar
14
-
Wagner Z, Heft-Neal S, Bhutta ZA, Black RE, Burke M, Bendavid E. Armed conflict and child mortality in Africa: a geospatial anal- ysis. Lancet. 2018;8:857–65.
DOI |
Google Scholar
15