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Table of Contents
Year : 2019  |  Volume : 27  |  Issue : 3  |  Page : 123-126

Child injuries in the Syrian Civil War

1 Departmant of Plastic, Reconstructive and Aesthetic Surgery, Dora Private Hospital, Istanbul, Turkey
2 Departmant of Plastic, Reconstructive and Aesthetic Surgery, Medical School of Mustafa Kemal University, Hatay, Turkey

Date of Web Publication4-Jul-2019

Correspondence Address:
Dr. Muzaffer Durmus
Dora Hospital, Plastic, Reconstructive and Aethetic Surgery Clinic, Istanbul
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_35_18

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Objective: During wars, many soldiers and civilians either get injured or die. In civil wars, older people, women, and children are more vulnerable to injuries and traumas. The aim of this study is to reveal the demographic features and variety as well as the characteristicsof the injuries in children who were impacted from the Syrian civil war and underwent surgeries in the plastic, reconstructive and aesthetic surgery department. Patients and Methods: This is a retrospective study which initially included 121 children aged 0–18 years out of a total of 402 Syrian patients treated in the plastic, reconstructive and aesthetic surgery department between December 2011 and December 2016. Results: Of 83 children with war injuries treated in our clinic, 42% were female and 58% were male. Forty-one percent of the injuries were located in the head-neck region. 43.4% of the injuries were due to burns. Thirty-six percent of the injuries were located on the extremities. All the patients underwent a total of 242 surgeries. The mean number of surgeries per child was 2.9. The mean time of hospitalization was 17.12% days. Conclusion: The results of the study show that children are impacted just as much or more thanadults in the Syrian civil war and had more severe injuries than those effected by similar wars and terrorist attacks.

Keywords: Child, injury, surgery, Syria, war

How to cite this article:
Kahraman A, Ozkan M, Durmus M. Child injuries in the Syrian Civil War. Turk J Plast Surg 2019;27:123-6

How to cite this URL:
Kahraman A, Ozkan M, Durmus M. Child injuries in the Syrian Civil War. Turk J Plast Surg [serial online] 2019 [cited 2021 Dec 5];27:123-6. Available from: http://www.turkjplastsurg.org/text.asp?2019/27/3/123/262128

  Introduction Top

The most frequent cause of the civilian death in wars is bombings. Explosions affect all people regardless of age groups in places where civilians live.[1] However, the possibility of survival is lower among children and older people than in adults. It has been reported in the literature that the death rate was 12.3% in people aged over 55 years and 5,9% in children aged under 18 years.[2]

Blast injuries can occur in two ways: due to pressure waves, as a result of sharp or blunt flying shrapnel or other objects, and as a result of pressure winds and burns due to thermal, chemical, and radiation exposures.[3],[4],[5] Most of the researches have focused on the psychological and sociological points of view, effects of biological and chemical weapons, or effects of wars on children.[6],[7],[8],[9] Terrorist attacks in the civilian areas cause head-neck injuries, contusions and abrasions, contaminated soft tissue injuries, and burns in children. In addition, various fractures, dislocations, ocular injuries, and burns may occur.[10]

Civilians, particularly children who are injured in wars, are usually treated in safer, neighboring countries. Turkey has been one of the main countries where civilians injured in the Syrian civil war have been treated. Therefore, this study seeks to reveal the demographic features and types, as well as the characteristics of injuries in children treated in our department.

  Patients and Methods Top

This is a retrospective study which initially included 121 children aged 0–18 years out of a total of 402 Syrian patients treated in the plastic, reconstructive surgery department between December 2011 and December 2016. The city (Hatay) is located on the furthest southern border of Turkey and neighbors with Syria on the south and the east borders. It is about 50 km from the city center to the Syrian border. The Syrian children who received hospital care for reasons other than war injuries were excluded from the study. As a result, 83 Syrian children who underwent surgery for war injuries or acute war injuries due to blast effect and/or shrapnel and burns were included within the scope of this study [Figure 1], [Figure 2], [Figure 3]. The data about age, gender, type, and location of the injuries, the duration of hospital stay, and the type and number of surgeries were obtained from the patient records. Injuries caused by sharp objects and tissue losses were usually found to contact with soil and other foreign bodies. The injuries were mostly observed to be contaminated due to primary sutures put in the war area to stop or control bleeding. Therefore, some patients were exposed to several sessions of debridement and wound care. The wound care was performed usually with povidone-iodine and isotonic saline or sometimes with hydrogen peroxide. Topical creams containing nitrofurazone, chloramphenicol, bacitracin plus neomycin sulfate, and sulfadiazine were used for standard dressing daily. Vacuum-assisted closure therapy was required in some patients. All the patients were administered systemic antibiotic therapy. The patients whose injuries were appropriate for surgery were operated as quickly as possible to shorten the length of the hospital stay. Since the patients usually go and live under difficult conditions in their country where the war still continues, extreme care was given to preserve as much tissue as possible.
Figure 1: An 8-year-old girl with severe burn injuries in the head-neck region due to an air raid 2 years ago. Her view after serial operations during follow-up period

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Figure 2: A 14-year-old boy who lost his eyes due to an explosion

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Figure 3: A 16-year-old boy suffered from the injuries of lower extremities. Preoperative (a) and postoperative (b) X-ray showing tibial bone reconstruction with fibular flap

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  Results Top

Of 83 children with war injuries included within the study, 42% were female and 58% were male. The mean age of the patients was 9.2 years (range: 1–17 years). The mean age of the males and the females was 10.6 and 7.3 years, respectively [Table 1]. 13.4% of the patients had sequels due to second- and third-degree burns and prior burns. Seventy-two percent of the burns were located on the head and neck. Other penetrating wounds, usually in the form of lacerations, fractures, or injuries characterized by tissue loss, were most frequently located on the head and neck (9.6%), followed by upper extremities (4.8%), lower extremities (26.5%), multiple body parts (9.6%), and the trunk (6%) [Table 2]. Forty-one percent of the patients had head-and-neck injuries. The total number of surgeries performed was 242. Of 242 surgeries, 13 were tendon repair, 12 were vessel repair, 18 were nerve repair, 59 repair with a local flap, 5 were require a free flap, 105 were need to a skin graft, 13 were reconstruction due to facial bone fractures, 5 were bone graft, 2 were nasal reconstruction, 3 were parotid duct repair, and 7 were fasciotomy/escharotomy [Table 3]. The mean duration of hospital stay was 17.12 days (range: 1–113 days) and the mean number of surgeries per patient was 2.5 (range: 1–12) [Table 1]. Examples of the head and neck and extremity injuries can be seen in [Figure 1], [Figure 2], [Figure 3].
Table 1: Demographic features of the children with war injuries

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Table 2: Distribution of war injuries in anatomic region in childhood period

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Table 3: Types of plastic and reconstructive surgery procedures and the distribution of the patients

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  Discussion Top

Since the beginning of the Syrian war, a total of 320,000 people, of whom 12,000 were children, have died and 1.5 million people have been injured or had permanent disabilities.[11] It has been shown by many studies that air raids most frequently cause head-and-neck injuries. They have considerably high rate of mortality. During bombings in the civilian areas, 90% of deaths in children have been reported to have taken place due to head traumas.[1],[10],[12] In the present study, the effects of sharp or blunt flying objects or shrapnel and burns due to thermal, chemical, and radiation exposures were observed to cause more severe and larger injuries in the children who underwent plastic and reconstructive surgery. There have been many studies in the literature which assess war injuries in soldiers undergoing plastic and reconstructive surgery. However, our study has set out to evaluate war injuries in children from the viewpoint of plastic and reconstructive surgeries.[13] It is possible to argue that people injured in the civil wars and armed conflicts have been treated under difficult conditions without any patient admission records in hospitals in the war fields. In several studies, combat and noncombat injuries have been evaluated through the general wound criteria. In one study, the mean number of surgeries performed per child was 1.6 and the mean duration of hospital stay was 4.5 days in Afghanistan. In the war in Iraq, the mean number of surgeries per child was 1 and the mean duration of hospital stay was 2.8 days. In addition, burns were responsible for 18.1% of noncombat injuries in Afghanistan and 32.6% of noncombat injuries in Iraq.[14] In another study, the mean duration of hospital stay was 5 days for children injured in terrorist attacks and 2 days for children injured in accidents. In addition, noncombat burns were 8% of injuries.[15] Another study revealed that the rate of burns in children in the normal population was 20.3%. When compared to the rates reported in the literature, the rate of burns was considerably high (43.4%). Moreover, when the duration of hospital stay, number of surgeries per child, and percentages of burns detected in the present study were compared with those reported from other studies. Injuries due to traffic accidents in children enrolled to the emergency departments are located on the head and neck in 27.8% of the cases, in the upper extremities in 12.2% of the cases, and in the lower extremities in 17.7% of the cases.[16] The rate of war-related head-neck injuries found in the present study seems to be higher than those of noncombat head-and-neck injuries reported so far; however, the difference was not very remarkable. Higher rates of burns and a wide variety of and higher frequencies of sharp force injuries in the current study can be attributed to highly destructive new weapons which have been manufactured recently. The fundamental principle underlying the development of new weapons is to maximize the destructiveness of wars. In fact, the present study has shown that sharp force injuries in the soft tissues, muscles, nerves, and vessels were caused by flying shrapnel and other objects. This can also explain the wide variety of surgeries performed [Table 2]. As war-related penetrating and blunt injuries of the head and neck are accompanied by cerebral traumas, they are treated in the neurosurgery departments. When the number of the patients admitted to the neurosurgery departments and the number of those presenting to the plastic and reconstructive surgery departments were added, it turns out that the total number of head-and-neck injuries is higher. However, as the injuries treated in the present study were only war-related, it has not been possible to compare the combat and noncombat injuries in the Syrian population. Therefore, the combat injuries found in this study would be compared with noncombat injuries from other populations.

  Conclusion Top

The combat injuries in Syrian children are more severe than the injuries which occur as a result of the wars and terrorist attacks in other countries reported so far. It is clear that new-generation weapons causing explosions and burns used in air raids are the most frequent cause of head-and-neck injuries.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Wade CE, Ritenour AE, Eastridge BJ, Young LA, Blackbourne LH, Holcomb JB. Explosion injuries treated at combat support hospitals in the global war on terrorism. In: Elsayed NM, Atkins JL, editors. Explosion and Blast-Related Injuries: Effects of Explosion and Blast from Military Operations and Acts of Terrorism. Burlington, MA: Elsevier Academic Press; 2008. p. 41-70.  Back to cited text no. 2
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Patt HA, Feigin RD. Diagnosis and management of suspected cases of bioterrorism: A pediatric perspective. Pediatrics 2002;109:685-92.  Back to cited text no. 7
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What you Need to Know: Crisis in Syria, Refugees, and the Impact on Children; 4 December, 2015. Available from: http://www.worldvision.org/news-stories/syria-war-refugee-crisis. [Last accessed on 2015 Jan 02].  Back to cited text no. 11
O'Keefe G, Jurkovich GJ. Measurement of injury severity and co-morbidity. In: Rivara FP, Cummings P, Koepsell TD, Grossman DC, Maier RV, editors. Injury Control. Cambridge: Cambridge University Press; 2001. p. 32-6.  Back to cited text no. 12
Sharony Z, Eldor L, Klein Y, Ramon Y, Rissin Y, Berger Y, et al. The role of the plastic surgeon in dealing with soft tissue injuries: Experience from the second Israel-Lebanon war, 2006. Ann Plast Surg 2009;62:70-4.  Back to cited text no. 13
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Aharonson-Daniel L, Waisman Y, Dannon YL, Peleg K, Members of the Israel Trauma Group. Epidemiology of terror-related versus non-terror-related traumatic injury in children. Pediatrics 2003;112:e280.  Back to cited text no. 15
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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]


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