Long-term health effects after conflict-related traumatic amputation among patients in Gaza

Background: In the past 10-15 years, thousands of civilians in Gaza have experienced conflict-related traumatic injuries. How injuries affect survivors' risks of negative long-term health effects and serious illness is unclear. We report follow-up findings in a group of patients with traumatic amputations.

Methods: Eligible patients had traumatically amputated limbs and showed signs and symptoms of possible serious illness on standardised clinical examination. The patients were all receiving rehabilitation treatment at the Artificial Limbs and Polio Centre, Gaza, which is the main provider of rehabilitation and protheses. All patients had suffered from at least one amputation during Israeli military incursions between 2006 and 2016. All were offered referral to the Al-Shifa Hospital, Gaza, for further diagnostic clinical, radiological, and laboratory tests. Each patient was examined by CT of the abdomen (or ultrasonography if CT could not be performed) and chest and MRI of the amputation stump or stumps. Laboratory analyses included ESR, complete blood count, kidney and liver function tests, serum glucose, creatine kinase, lactate dehydrogenase, and hepatitis B and hepatitis C virus infections.

Findings: Of 254 traumatically amputated patients assessed, 105 had signs and symptoms of possible serious illness, among whom 94 accepted referrals. 88 (93%) of 94 were men and the median age was 31.5 years, mean age 34 years (SD 9·6). Of 90 patients who had imaging, 19 (21%) patients had fatty liver infiltration, three (<1%) had lung nodules, and ten had lung atelectasis. Shrapnel was found in the chest of 12 patients (13%), the abdomen of five patients (6%), the scrotum of one patient (<1%), in the amputation stumps of 26 patients (29%), and the non-amputated limbs of eight patients (1%). Three (<1%) of 90 patients had liver lesions. 32 (34%) of 94 patients had elevated ESR, 19 (20%) had elevated liver enzyme concentrations, and 12 (13%) were anaemic. Two patients tested positive for hepatitis C virus and three were positive for hepatitis B virus (one with fatty liver changes). Two of the 19 patients with fatty liver infiltration were diagnosed as having type 2 diabetes. A limitation of this study is that, owing to conflict-related supply-chain issues in Gaza, we were unable to collect complete data in four (5%) of patients.

Interpretation: As well as residual shrapnel in more than half of patients, a notable proportion of patients had fatty liver infiltration, for which we have no clear hypothesis. We recommend close medical follow-up for trauma patients in injured by explosives.

Funding: The Norwegian street-artist AFK provided €1,500 to this project, which was used to cover patients' transportation costs.