Delayed surgery leaves lasting nerve damage in Tigray war wounded

Most patients with conflict-related injuries arriving at the largest referral hospital in Ethiopia’s Tigray region had waited months or even years before their first surgical assessment, and that delay fundamentally shaped what doctors could do for them. A retrospective observational study conducted at Ayder Comprehensive Specialized Hospital in Mek’ele between September and December 2023 found that among 197 conflict-related injuries analyzed, peripheral nerve damage was the most common diagnosis, affecting 54.3 percent of patients. Because so many patients presented long after their wounds were inflicted, primary nerve repair was rarely feasible, and the surgical teams instead had to plan secondary salvage procedures such as tendon transfers and muscle transpositions, which are significantly less effective than direct nerve repair.

The study, published in the journal Conflict and Health, was based on routinely collected clinical documentation from patients assessed during their first presentation to the hospital. Ayder is a tertiary referral and teaching hospital in Mek’ele, the capital of the Tigray region, and the largest referral centre for specialized care in northern Ethiopia, serving a catchment area of several million people. During and after the armed conflict that began in late 2020, the hospital continued to operate despite severe constraints in staffing, medical supplies, diagnostic capacity and referral pathways, and it remained one of the few facilities able to manage complex war-related injuries in the region.

The researchers identified 197 conflict-related injuries in total, of which 108, or 54.8 percent, were caused by bullets and 82, or 41.6 percent, by blasts, with the remaining 7 injuries attributed to other mechanisms. The analysis focused on the two largest groups. Nearly all patients were male, at 90.9 percent overall, but the gender distribution differed significantly between mechanisms: 97.2 percent of the bullet group and 81.7 percent of the blast group were male, a difference the authors noted was statistically significant. Patients ranged in age from 18 to 61 years, and the mean age did not differ significantly between the two groups, at 28.3 years for bullet injuries and 26.7 years for blast injuries.

The timing of presentation was one of the most striking findings. Among the roughly half of patients who had undergone at least one operation or surgical procedure as part of their initial hospital care, those procedures had occurred on average 24.8 months before presentation for the bullet group and 23.5 months before presentation for the blast group. In other words, most patients arrived for specialized assessment approximately two years after being wounded. The authors report that this delay severely limited the feasibility of primary nerve repair and reconstructive procedures, forcing reliance on secondary interventions that provide some functional recovery but are inherently suboptimal compared with acute repair.

The pattern of complaints and clinical findings differed clearly by injury mechanism. Bullet injuries were more strongly associated with movement restrictions and functional deficits, whereas blast injuries were more frequently linked to fractures, soft tissue defects, scars and wounds, and persisting pain. In the statistical models, the probability of complaining of movement restrictions due to bullet injuries rose from 24.7 percent at age 18 to 38.1 percent at age 60, while the probability of functional deficits within bullet injuries decreased from 52.3 percent to 37.5 percent across the same age range. Fractures were significantly less common in bullet injuries, and their prevalence increased slightly with age, particularly among blast-injured patients.

Peripheral nerve injuries dominated the clinical picture. More than half of all patients, 107 individuals, presented with injuries to one or more peripheral nerves, and across the entire cohort a total of 170 injured nerves were observed. In total, 76 patients, or 38.6 percent, had injuries to peripheral nerves of the upper extremity, including the axillary, radial, median and ulnar nerves, while 84 patients, or 42.6 percent, had injuries to lower extremity nerves such as the sciatic, femoral, tibial and common peroneal nerves. The distribution differed significantly by mechanism: gunshot injuries showed a notable predominance of lower extremity nerve involvement, with 55.1 percent of bullet-injured patients affected in the lower extremities compared with 20.6 percent of blast-injured patients.

Combined nerve injuries were also common, affecting 28 patients, or 26.2 percent of those with nerve injuries. In the upper extremity, combined ulnar and median nerve injuries were the most frequent pattern, documented in 15 patients, while in the lower extremity, combined common peroneal and tibial nerve injuries occurred in 6 cases. The authors suggest that this high prevalence of multi-level nerve trauma indicates that many patients sustained complex injuries carrying a high risk of functional impairment, loss of mobility and reduced quality of life. They also note that because 97 patients, or 49.2 percent, had undergone one or more previous surgeries before presenting for evaluation, nerve injuries may have been overlooked or inadequately diagnosed during initial treatment, leading to sequential procedures rather than definitive repair.

The planned surgical treatments reflected this burden. Tendon and muscle surgeries were the most common planned interventions, accounting for 30.9 percent of all planned procedures, followed by corrective and functional surgeries at 27.2 percent and supportive treatments at 19.8 percent. Reconstructive surgeries accounted for 11.3 percent and scar and contracture surgeries 8.3 percent, while procedures involving limb or tissue removal were rare at 1.5 percent, indicating that limb salvage and reconstructive efforts were prioritized when possible. Only two patients, 0.8 percent, did not require any surgical intervention. Analyzed by mechanism, blast injuries showed a higher frequency of reconstructive surgeries and scar or contracture releases, whereas bullet injuries more frequently required corrective and functional surgeries such as secondary fracture management. Only a very small proportion of patients had direct nerve surgery planned at presentation, regardless of mechanism, suggesting that reconstructive nerve procedures were rarely considered feasible under the prevailing resource constraints.

The study sits within a broader picture of conflict injury in the region. The authors cite earlier research reporting that in the first eight months of the war in Tigray, approximately 13.8 out of every 1,000 residents sustained war-related injuries, a prevalence they note is higher than figures reported for the 2014 Gaza war, Baghdad, and Libya, and that gunshot wounds accounted for roughly two-thirds of reported injuries in that earlier work. Globally, the Heidelberg Institute for International Conflict Research documented 369 conflicts in 2023, with sub-Saharan Africa the region with the highest number of wars.

The authors acknowledge important limitations. The study was single-centre, so the findings may not generalize to other conflict settings with different healthcare infrastructure and injury mechanisms. Some variables relied on patient-reported histories, introducing the possibility of recall bias, and the cohort includes only patients who were able to reach medical care, potentially excluding those who died before reaching the hospital or who could not access healthcare during the conflict. There was also no control group of similar injuries in non-conflict settings. The authors emphasize that the conceptual pathway they describe, linking conflict injuries through health-system disruption and delayed care to long-term disability, is an interpretive summary of their findings rather than a tested causal model. They conclude that improving access to acute trauma care, early nerve repair, reconstructive surgery and rehabilitation is essential to reduce disability in conflict-affected settings, and they suggest that specialized surgical teams deployed to similar settings should include expertise in reconstructive and peripheral nerve surgery, orthopaedic or trauma surgery, anaesthesia, and perioperative nursing, coupled with strategies to ensure timely access to injured patients during active conflict.

Subject of Research: Delayed surgical care and peripheral nerve injuries among conflict-related trauma patients in Tigray, Ethiopia

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

Article References: Klausing, A., Bruchhausen, W., & Wynands, J. (2026). Surgery under fire: war injuries and the consequences of delayed care in Ethiopia’s Tigray region. Conflict and Health, 20(1), Article 84. https://doi.org/10.1186/s13031-026-00853-7

Image Credits: AI Generated

DOI: 10.1186/s13031-026-00853-7

Keywords: Tigray, Ethiopia, conflict injuries, peripheral nerve injuries, blast injuries, gunshot wounds, delayed surgical care, reconstructive surgery, tendon transfers, Ayder Comprehensive Specialized Hospital, war trauma, disability