Over the past few years, our Egyptian tertiary hospitals have received many injured patients from nearby countries where wars are rising.
The ongoing conflicts in these countries do not only impact military personnel, but also have an immeasurable effect on the civilian population. Since many hospitals across these countries have been hit and are now semi-functional or destroyed [4], patients are transferred to more secure and more efficiently equipped nearby countries, such as Egypt.
Being a rising subject in the last few years, only a few researchers studied the firearm and missile injuries in conflict zones; either focusing on the cranial and maxillofacial injuries as in Pabuscu et al. study [5] or describing the types and patterns of injuries as in Wild et al. study [2], yet, not from a radiological point of view as in our study.
Our role as radiologists is to determine the exact sites and types of combat-related injuries, the associated soft tissue, bone, or vascular injuries, as well as the possible delayed or postoperative complications.
According to the study conducted by Wild et al., patients with conflict-related injuries were predominantly males, and most of them were of young age with a mean age of 26 years [2].
Also, Bodalal and Mansor found that the incidence rates of gunshot injuries indicate strong male predilection with males being over 20 times more likely to be shot during the war than females and that the average age of gunshot patients was 28.32 years [6].
This was more or less consistent with our study in which all patients were males with a mean age of 28.9 years.
In Pabuscu et al. study, bullets and metallic foreign bodies were identified in 70.7% of patients wounded by gunshots and fragmentation bombs [5], whereas in our study, 61.4% of patients displayed bullets and metallic foreign bodies of different sizes and shapes in different locations of the body, but in the remaining 38.6%, the bullet or the metallic fragments did not lodge in the patients’ bodies.
Wild et al. stated that the extremities were the most common anatomical regions involved by combat-related injuries composing 33.5% of them, followed by head and neck injuries in 18%, and soft tissue wounds in 14%, while thoracic and abdominal injuries were less common and accounted for 10.4 and 7.5%, respectively [2].
Similarly, Bodalal and Mansor declared that 68.9% of gunshot injuries occurred in the limbs with the lower limbs most commonly affected, followed by the upper limbs and the chest [6].
In concordance with these studies, injuries involving the musculoskeletal system of the extremities were the most frequent in our patients representing about 77.2%, followed by maxillofacial injuries in 41%, chest injuries in 32.1%, cranial injuries in 31%, and abdominal injuries in 21.1% of patients.
Among the extremity injuries, fractures were the most common comprising about 68.5%. In fact, bone fractures were by far the most prevailing type of injury across all systems in our study as upper limb fractures were encountered in 69 (40.4%), lower limb fractures in 48 (28.1%), maxillo-facial fractures in 26 (15.2%), spinal fractures in 15 (8.8%), chest wall fractures in 21 (2.3%), and calvarial fractures in 9 (5.3%) patients.
Comparing combat-related civilian injuries to military personnel injuries from literature revealed similar injury patterns between the two groups, as the consensus through current war trauma literature is that between 65 and 70% of war wounds involve the musculoskeletal system [7]. Also, Cameron and Owens state that the burden of musculoskeletal combat-related wounds in military personnel is very high with extremity wounds representing 54% of all wounds [8].
Likewise, Griffiths and Clasper declare that 70% of all wounds encountered during combat induced by various mechanisms such as bomb blasts and bullets affect the extremities with the lower limb predominantly affected [9].
In addition, Chandler et al. 2017 found that combat injuries more commonly involve the extremities than other body parts with fractures being the most frequently recorded injury and the lower limbs the most frequently involved site [10].
Similarly, Maričević and Erceg described the highest percentage of all combat injuries to the extremities accounting for 75% with bone fractures seen in 62% of the patients and the lower extremities the most commonly involved [11].
Although in Bodalal and Mansor study vascular lesions were very common, they were the least frequent type of injury in our study detected only in 4.7% of patients [6].
However, this was in similarity to military injuries described by Maričević and Erceg showing that gunshot wounds and fractures were relatively rarely associated with vascular injuries, although soft tissue wounds were frequently present [11].