Date of Award

January 2024

Document Type


Degree Name

Medical Doctor (MD)



First Advisor

Brianna R. Fram


Introduction:This thesis critically examines the epidemiological trends and clinical outcomes associated with ballistic and explosive orthopedic trauma, focusing exclusively on data coming from low- and middle-income countries (LMICs). Given the rising prevalence of civilian casualties in contemporary conflict zones and incidents of urban gun violence, there is an amplified need to bolster our understanding of these injuries. This is particularly important in LMIC civilian settings where a majority of this trauma is occurring but where the current literature is extremely lacking. This research aims to contribute significantly to the global medical community's capacity to provide informed, LMIC relevant evidence-based care to serve the growing need in these regions of the world. Methods: We conducted a retrospective analysis using the Surgical Implant Generation Network (SIGN) Fracture Care database, which includes data from over 100,000 cases of surgically treated orthopedic fractures coming from 425 partner sites in 57 LMIC countries. The SIGN implants primarily center around the use of an intramedullary fixation devices but do also contain plates and screws for fixation. Injury cause data was collected starting in 2016, thus all cases with a documented injury cause between January 1st, 2016, and January 30th, 2023, were included in our study. The study's scope covered demographic data, injury causation, therapeutic interventions, and follow-up results, with a particular emphasis on infection rates (minimum follow-up 30 days), instances of nonunion (minimum follow-up 180 days), and the capability for painless weight bearing (minimum follow-up 90 days) as a measure of functional recovery. Data organization and analytical procedures were conducted using R, incorporating both univariate and multivariable logistic regression to distill associations and outcomes. Multivariable analysis was limited to the infection outcome only due to higher rates of loss to follow-up with later follow-up time points. Complete case analysis was used for the multivariable analysis. Results: The study included 117,729 cases with a documented injury cause between 2016 and 2023. Of these, we identified 5,256 cases of ballistic fractures and 985 explosive-related fractures. The average time to surgery for these injuries was significantly longer than for other trauma types, with 40% of explosive and 30% of ballistic injury cases waiting over 30 days for surgery (p = <0.001). The rate of infection was notable at 6.6% for ballistic injuries and 7.6% for explosive traumas. Multivariable analysis demonstrated that ballistic fractures had an increased infection risk with larger surgical delays and explosive blast-related fractures had an increased infection risk with increasing injury severity and decreased infection risk when given antibiotics. Painless weight bearing, an indicator of successful recovery, was reported in 80.8% of ballistic injury cases and 73.2% of those with explosive injuries at 90-days from injury. Furthermore, nonunion was a significant postoperative complication, manifesting in 12.0% of ballistic and 14.8% of explosive injuries. Our univariate analysis demonstrated that for ballistic fractures protracted time to surgery was associated with an increased rate of nonunion and antibiotics were associated with a decreased rate of nonunion. Conclusion: The study's results reveal critical delays in the provision of surgical care and potentially elevated complications such as infection and nonunion compared to data from high-income countries. This appears to be especially pronounced for explosive blast-related fractures. It is important to interpret these data in the context of the SIGN database, which may not be wholly applicable to all LMIC settings. Nevertheless, these results represent the investigation of one of the largest known databases of conflict-related injuries in LMIC civilian populations to date. The results likely reflect the many challenges of treatment for these injuries that are exacerbated in LMICs, where limited resources and infrastructural deficits pose additional hurdles. The necessity for enhanced surgical response times, improved infection prevention, and judicious antibiotic use is clear. The research also underscores the urgent need for comprehensive, context-specific investigations and interventions in LMICs, and it advocates for integrative clinical practices and public health policies tailored to the unique burdens of conflict-related orthopedic trauma. The outcomes of this thesis aim to guide the global health community in refining treatment protocols and to support international surgeons in the delivery of more effective orthopedic trauma care.


This thesis is restricted to Yale network users only. It will be made publicly available on 04/30/2025