How Do Gunshot and Explosive Injuries to the Lower Extremities Differ in Severity and Treatment? A Comparative Study From the Israel-Gaza Conflict.

BACKGROUND

Lower extremity injuries are common in conflict-related trauma, with gunshot wounds (GSWs) causing localized damage and explosive trauma leading to extensive tissue injuries. Existing research lacks direct comparisons of injury severity and treatment outcomes between GSWs and explosive trauma in modern conflicts. This study clarifies these differences to improve triage strategies, surgical planning, and rehabilitation protocols.

QUESTIONS/PURPOSES: (1) How did GSWs and explosive trauma differ in terms of injury severity, including the proportion of patients in each group who experienced open fractures, neurovascular injuries, and amputations, during the Israel-Gaza conflict? (2) What was the comparative frequency and type of surgical intervention performed for GSWs versus explosive trauma in lower extremities?

METHODS

Between October 7, 2023, and December 31, 2023, a total of 1815 patients were entered into the Israel National Trauma Registry (INTR) as having been injured during the Israel-Gaza conflict. The INTR 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, consistent reporting of war-related injuries. Of these, we considered patients with lower extremity injuries and ICD-9 E-codes E979 and E990-E999 (terror and war-related injuries) as potentially eligible. Based on this criterion, 1318 patients sustained extremity injuries, and 51% (674) met our inclusion criteria for this study. Among them, 53% (357 of 674) sustained GSWs and 47% (317) suffered explosive injuries. The groups did not differ in terms of mean ± SD ages (gunshot 28.5 ± 11.7 years, explosive 28.0 ± 11.4 years; p = 0.61). Most patients in both groups were men (gunshot 91%, explosive 95%; p = 0.09), with no between-group difference in terms of the proportion of patients who were men. Missing data were minimal in both groups, with complete data sets available for all primary outcomes. Comparisons were made between the two groups regarding the severity of injuries (such as open fractures and amputations), frequency and type of surgical interventions, and associated injuries (including those to the chest, abdomen, and face). Statistical analysis included chi-square tests for categorical variables and independent t-tests for continuous variables, with a significance threshold of p < 0.01 because of the large number of comparisons made.

RESULTS

GSWs resulted in a higher proportion of patients with open fractures (32% [115 of 357] versus 20% [64 of 317]; p = 0.001), particularly in the tibia and fibula (17% [62 of 357] versus 10% [33 of 317]; p = 0.01), whereas explosive injuries led to more amputations (10% [31 of 317] versus 3% [11 of 357]; p < 0.001); neurovascular injuries did not differ (p = 0.14 for nerve and p = 0.54 for vascular). A higher proportion of gunshot injuries were treated surgically (73% versus 59%; p < 0.001).

CONCLUSION

Understanding the distinct injury patterns and outcomes of GSWs and explosive trauma is essential for improving patient care and resource allocation during conflicts. Given the high amputation rates in blast injuries, early rehabilitation and prosthetic support should be prioritized, while gunshot-related open fractures often call for expanded orthopaedic fixation and infection control. Trauma training should emphasize early surgery for GSWs and hemorrhage control for blast injuries. Future research should focus on long-term functional outcomes, protective gear efficacy, and improved battlefield evacuation strategies to enhance survivability and recovery.

LEVEL OF EVIDENCE

Level III, therapeutic study.