Do Gunshot and Explosion Injuries Differ in Severity and Management? A Multicenter Study of Upper Extremity Trauma in the 2023 Israel-Gaza Conflict

Abstract

Background: In 2023, the Israel-Gaza conflict escalated with the October 7, 2023, attack that has led to prolonged warfare. Upper extremity injuries, often resulting from explosions or gunshot wounds, have been a major cause of disability in this conflict. While previous studies have examined blast and ballistic trauma separately, there is a lack of direct, large-scale comparisons of their injury patterns, severity, and clinical management in a real-world conflict setting. It remains unclear whether gunshot wounds or explosion-related injuries result in more intensive surgical interventions or more frequent complications. Addressing these gaps is critical for improving trauma care and resource allocation in conflict zones.

Questions/purposes: (1) What are the primary differences in injury patterns and severity, including the proportion of patients in each group who experienced open fractures, neurovascular injuries, and amputations between explosion-related and gunshot-related upper extremity injuries during the Israel-Gaza conflict? (2) How do the type and frequency of surgical interventions differ between patients with explosion-related and gunshot-related upper extremity injuries?

Methods: Between October 7, 2023, and December 31, 2023, a total of 1815 patients were recorded in the Israel National Trauma Registry as having sustained injuries during the Israel-Gaza conflict. The Israel National Trauma Registry is a comprehensive national database that collects standardized injury and treatment information from all Level 1 and Level 2 trauma centers in Israel, ensuring high-quality and consistent reporting of war-related injuries. For this study, we identified patients with upper extremity injuries and ICD-9 E-codes E979 and E990-E999 (terror and war-related injuries) as potentially eligible. Based on these criteria, 695 patients sustained upper extremity injuries, and 86% (597) met our inclusion criteria. Among them, 49% (294 of 597) suffered gunshot wounds while 51% (303 of 597) sustained explosion-related injuries. The study population was divided into two groups: patients with gunshot wounds and those with explosive trauma. Both groups had similar mean ± SD ages, with gunshot-injured patients being slightly older overall (gunshot 30 ± 13 years, explosive 27 ± 9 years; p = 0.006). Most patients in both groups were men (gunshot 91%, explosive 98%; p < 0.001), with a higher proportion of women patients in the gunshot group. Missing data were minimal, and we had complete data sets for all primary outcomes. The two groups were compared based on injury severity (including fractures, nerve injuries, and amputations), frequency and type of surgical interventions, and associated injuries to other body regions. Because of the large number of comparisons made, p < 0.01 was considered statistically significant.

Results: Patients with gunshot-related injuries typically had higher severity scores (Injury Severity Score 16 to 24 [severe injury] 18% [52 of 294] versus 10% [31 of 303] and Injury Severity Score 25 to 75 [critical injury] 12% [35 of 294] versus 10% [31 of 303]; p < 0.001) and a greater proportion of patients with nerve injuries (14% [41 of 294] versus 8% [23 of 303]; p = 0.001) and associated fractures (53% [157 of 294] versus 33% [99 of 303]; p < 0.001), whereas explosion-related injuries were characterized by more concomitant injuries in other body regions (79% [240 of 303] versus 64% [188 of 294]; p < 0.001). Gunshot injuries were more commonly treated surgically (79% [231 of 294] versus 55% [168 of 303]; p < 0.001) and resulted in longer hospital stays, with a higher proportion staying over 7 days (42% [124 of 294] versus 31% [93 of 303]; p < 0.001).

Conclusion: Given the distinct injury patterns and treatment needs identified in this study, trauma surgeons should anticipate a higher likelihood of severe nerve injuries, fractures, and surgical interventions in patients with gunshot wounds, often calling for early and aggressive management, including nerve repair and reconstructive procedures. Military planners and medical logisticians should ensure that trauma teams in conflict zones have access to specialized surgical expertise, early rehabilitation programs, and sufficient resources for infection control and wound management. Additionally, training in nerve repair techniques and damage control orthopaedics should be emphasized for frontline surgeons. Future studies should focus on long-term functional outcomes of these injuries, exploring strategies to improve rehabilitation and limb salvage techniques in combat settings.

Level of evidence: Level III, therapeutic study.