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hospitals, adhering to clinical guidelines and protocols estab- FIGURE 1 PRISMA 2020 flow diagram.
lished by the Ukrainian Ministry of Health. Moreover, health-
care authorities must coordinate efforts to ensure high-quality
care while maintaining sufficient medical resources for the
broader population. 12
This systematic review aims to synthesize available literature
on orthopedic and musculoskeletal injuries sustained during
the ongoing conflict in Ukraine. Specifically, it seeks to char-
acterize the nature and mechanisms of these injuries, evaluate
current clinical management practices, and identify areas for
future research in combat-related trauma affecting both mili-
tary and civilian populations.

Methods
Study Protocol, Search Strategy, and Data Collection
This systematic review was conducted in accordance with
the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) guidelines. The protocol was not
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registered with PROSPERO. A comprehensive literature search
was carried out in February 2025 across four electronic data-
bases: PubMed, Scopus, Web of Science (WoS), and MEDLINE
via WoS. The search strategy combined relevant keywords and
Boolean operators tailored to each database’s indexing system,
using the following terms: ((“combat injury” OR “war wound”
OR “battlefield injury” OR “blast injury” OR “gunshot
wound” OR “war-related trauma” OR “military personnel” Screening, study selection, and data extraction.
OR “soldier” OR “combatant” OR “casualty” OR “ortho-
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pedic surgery” OR “fracture fixation” OR “amputation” OR as high quality. Observational studies were evaluated using
“external fixation” OR “wound management” OR “damage the Strengthening the Reporting of Observational Studies in
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control surgery” OR “trauma surgery” OR “emergency sur- Epidemiology (STROBE) guidelines. Any disagreements in
gery” OR “war injury” OR “war surgery” OR “wound man- quality assessment were resolved by a third reviewer.
agement”) AND (“Ukraine” OR “Ukrainian conflict” OR
“Russia-Ukraine war” OR “invasion of Ukraine”)). Data Synthesis
A qualitative synthesis was performed by systematically sum-
The number of records retrieved from each database is de- marizing the extracted data and assessing study quality. Quan-
tailed in the PRISMA 2020 flow diagram (Figure 1), which titative data were analyzed using descriptive statistics, with
provides a clear overview of the search scope and the study median and range for continuous variables and frequency and
selection process. percentage for categorical variables.

Two independent reviewers (RTB and CRM) screened the ti- Results
tles and abstracts of identified studies, followed by a full-text
review to confirm eligibility based on pre-specified inclusion Literature Search
criteria. Any disagreements were resolved by a third reviewer The database search yielded 2,483 studies, of which 1,138 du-
(AHA). Eligible studies included clinical research on orthope- plicates were removed. After screening 1,345 studies based on
dic and musculoskeletal injuries sustained during the Ukraine title and abstract, 456 were excluded as irrelevant. Full-text
conflict. No language restrictions were applied. Non-English screening of 397 studies resulted in the inclusion of 31 eligible
studies were included if they met the inclusion criteria and studies. The PRISMA flow diagram summarizing the study se-
were translated by fluent collaborators, encompassing case lection process is presented in Figure 1.
reports, case series, cohort studies, cross-sectional analyses,
and randomized controlled trials (RCTs), regardless of lan- Study Characteristics
guage, patient demographics, or other restrictions. Studies that The 31 included studies, conducted between 2014 and 2024,
did not focus on orthopedic trauma were excluded. A third focused on military-related injuries resulting from the ongoing
reviewer resolved any discrepancies in the selection process. Ukraine conflict. The majority were case reports and retrospec-
Data extraction was performed by two authors, adhering to tive analyses, while observational studies (comparative, cohort,
the predefined inclusion criteria. and descriptive) accounted for seven studies. Case- control and
prospective clinical studies were less frequent. Most research
Quality Assessment was conducted in Ukraine, primarily within military medical
Study quality was assessed using the Joanna Briggs Institute facilities and frontline hospitals. However, four studies exam-
(JBI) critical appraisal tools, which evaluate case reports and ined Ukrainian patients treated abroad in Germany, Spain,
case series for methodological rigor. Case reports scoring and the Netherlands. The studies spanned various healthcare
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four or lower were classified as low quality, those scoring five settings, including battlefield hospitals, level II–IV medical fa-
to six as moderate quality, and those scoring seven to eight cilities, and specialized rehabilitation centers. The number of

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