Annals of African Medicine
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Table of Contents
Year : 2015  |  Volume : 14  |  Issue : 2  |  Page : 114-117  

Pattern of injuries seen during an insurgency: A 5-year review of 1339 cases from Nigeria

1 Department of Orthopaedics and Trauma Surgery, College of Medical Sciences, University of Maiduguri, Maiduguri, Nigeria
2 Department of General Surgery, College of Medical Sciences, University of Maiduguri, Maiduguri, Nigeria
3 Department of Anesthesiology, College of Medical Sciences, University of Maiduguri, Maiduguri, Nigeria

Date of Web Publication19-Feb-2015

Correspondence Address:
T M Dabkana
Department of Orthopaedics, College of Medical Sciences, University of Maiduguri, Maiduguri
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1596-3519.149910

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Background: When there is an insurgency, the use of force in the form of weaponry, is employed. This may lead to the total breakdown of law and order, resulting in destruction of life and property. Health workers may be killed or captured, and, health facilities destroyed or stretched beyond their functional capacity. This is a report of experience with injuries seen in a tertiary hospital in north eastern Nigeria, under an insurgency situation.
Materials and Methods: After obtaining clearance from the medical Ethics Committee of UMTH, we reviewed the case files of all patients treated for injuries sustained as a result of the Boko Haram insurgency from January 2009 to December 2013. Those brought in dead, were not included in the study.
Results: We reviewed the case files, theatre notes, admission and discharge registers of 1339 cases. 1223 (91.3%) of the victims were males, while 116 (8.7%) were females. Gunshot wounds accounted for 1229 (91.8%) of the injuries, bomb blast 90 (6.7%), others 15 (1.1%) knife (Cut throat) 4 (0.3%) and road traffic accident 1 (0.01%). Casualties were made up of civilians 1144 (85.4%), the joint task force (a force made up of the Military, Police, Customs and Immigration, against the insurgents) 117 (8.7%), and insurgents 22 (1.6%). The ages of the patients ranged from 1 to 80 years, peaking at the 21-40 age brackets (796 or 59.4%). The extremities were most affected, 734 (54.8%), followed by the torso 423 (31.6%), multiple injuries 93 (6.9%) and head and neck 89 (6.6%). 1226 (91.6%) of the victims survived while 113 (8.4%) died from their injuries. This followed massive blood loss from injuries to the torso 69 (61.1%) multiple injuries 15 (13.3) and extremities 6 (5.3%). Others causes were fatal injuries to the head and neck 22 (19.5%) and 90% burns following bomb blast 1 (0.9%).
Conclusion: Injuries resulting from insurgency will continue to be a problem in many developing countries because their health facilities in terms of personnel and materials are ill prepared for such a situation .

   Abstract in French 

Lorsqu'il y a une insurrection, le recours ΰ la force sous la forme d'armes, est employι. Cela peut conduire ΰ l'effondrement total de l'ordre, qui a entraξnι la destruction de la vie et les biens. Les agents de santι peuvent κtre tuιs ou capturιs et, centres de santι dιtruits ou s'ιtendait au-delΰ de leur capacitι fonctionnelle. Il s'agit d'un rapport d'expιrience avec les blessures constatιes dans un hτpital tertiaire au nord est du Nigeria, dans une situation d'insurrection.
Matιriaux et Mιthodes: Aprθs avoir obtenu l'autorisation de la Commission mιdicale d'ιthique de UMTH, nous avons examinι les dossiers de tous les patients traitιs pour des blessures subies ΰ la suite de l'insurrection de Boko Haram de janvier 2009 ΰ dιcembre 2013. Celles mises ΰ morts, n'ιtaient pas inclus dans l'ιtude.
Rιsultats: Nous avons examinι les dossiers, notes de thιβtre, admission et de dιcharge enregistre des cas de 1339. 1223 (91,3 %) des victimes ιtaient des hommes, tandis que 116 (8,7 %) ιtaient des femmes. Blessures par balles ont ιtι rapportιs ΰ 1229 (91,8 %) des blessures, bomb blast 90 (6,7 %), d'autres 15 (1,1 %) couteau (Cut throat) 4 (0,3 %) et le chemin de circulation accident 1 (0,01 %). Victimes ιtaient constituιs de civils 1144 (85,4 %), la joint task force (une force composιe de militaires, Police, douanes et Immigration, contre les insurgιs) 117 (8,7 %) et les insurgιs 22 (1,6 %). L'βge des patients varies de 1 ΰ 80 ans, atteignant un sommet ΰ l'βge de 21 ΰ 40 ans entre parenthθses (796 ou 59,4 %). Les extrιmitιs ont ιtι les plus touchιs, 734 (54,8 %), suivi par le torse 423 (31,6 %), de multiples blessures 93 (6,9 %) et de tκte et de cou 89 (6,6 %). 1226 (91,6 %) des victimes a survιcu tandis que 113 (8,4 %) sont morts de leurs blessures. Ce suivi perte de sang massive des blessures au torse 69 (61,1 %) des blessures multiples 15 (13.3) et extrιmitιs 6 (5,3 %). D'autres causes ont ιtι des blessures mortelles ΰ la tκte et du cou 22 (19,5 %) et de 90 % des brϋlures aprθs l'explosion d'une bombe 1 (0,9 %).
Conclusion: Blessures causιes par l'insurrection continueront ΰ κtre un problθme dans de nombreux pays en dιveloppement parce que leurs ιtablissements de santι en termes de personnel et les matιriaux sont malades prιparιs pour une telle situation.
Mots-clιs: Bonne et efficace des soins mιdicaux, insurrection (terrorisme), rιsultat du traitement, plan des blessures, protection civile

Keywords: Good and effective medical care, insurgency (terrorism), outcome of treatment, pattern of injuries, preparedness

How to cite this article:
Dabkana T M, Bunu B, Na'aya H U, Tela U M, Adamu A S. Pattern of injuries seen during an insurgency: A 5-year review of 1339 cases from Nigeria. Ann Afr Med 2015;14:114-7

How to cite this URL:
Dabkana T M, Bunu B, Na'aya H U, Tela U M, Adamu A S. Pattern of injuries seen during an insurgency: A 5-year review of 1339 cases from Nigeria. Ann Afr Med [serial online] 2015 [cited 2023 Mar 28];14:114-7. Available from:

   Introduction Top

Insurgency is an act perpetuated by an individual or group of people for idiosyncratic, criminal, political or religious reason. The actors are usually called terrorists [1] and the Boko Haram fall in here. This group is said to have been in existence since 1995 led by one Mallam Lawan. In 2002, Mohammed Yusuf took over the leadership when Lawan went to continue his education. His main followers were unemployed youths. He told his followers that the Western education (Boko) was not good (Haram) to the extent that graduates and school leavers destroyed their certificates. His teachings were abhorred by most Islamic teachers who later paid dearly with their lives. The sect became violent in 2009 when they clashed with the police leading to the death of some of their members; leaving scores wounded who were treated at University of Maiduguri Teaching Hospital (UMTH). Soon thereafter, they attacked police barracks, schools and churches in Maiduguri. This last act lead government to go after them with eventual arrest of their leader who was subsequently killed and his deputy Abubakar Shekau took over the leadership, and after regrouping, it has been a war on every one that was not on their side. Their initial targets were Christians and churches, but later all nonmembers also, including Muslims. Everyone became terrorized. Light weapons (A-K 47, pistols) and improvised explosive devices (IEDs) [2],[3] were usually the weapons of choice. Knives were also used to slaughter people in their houses. Boko Haram finances itself through bank robberies, ransoms and some unknown sources. Most developed countries that went through periods of terrorism have developed protocols for the prevention of attacks and treatment of victims, [4] but this is lacking in most developing countries such as Nigeria where these acts are new. The dearth of medical expertise and well equipped health facilities to manage victims of terror attacks has made a bad situation worse.

   Materials and Methods Top

This was a retrospective review of cases following insurgency attacks treated at the UMTH from January 2009 to December 2013. Data was extracted from patient case notes, operation, admission and discharge registers using a proforma. This data include name, age, sex, occupation, cause of injury, and outcome of treatment. Those that were brought in dead were not included in the study.

   Results Top

We reviewed the case files, theatre records, admission and discharge registers of 1339 patients who were victims of the Boko Haram insurgency from January 2009 to December 2013. We did observe that:

  1. Most victims were between the ages of 21 and 40 years [Figure 1]a-d
  2. Most victims were males
  3. No religious, ethnic or occupational bias
  4. Most deaths resulted from chest, abdominal, head and neck injuries
  5. The lower limbs were mostly injured, followed by upper limbs, chest and abdomen
  6. That survival of victims was determined by the time it took the patient to arrive hospital from time of injury, part of the body injured and amount of blood lost
  7. That almost 95% of the victims had no form of treatment before arriving hospital
  8. That 11 (50%) of those with head and neck injuries died within 24 h of arrival at the hospital
  9. That all the gunshot wounds were from high-velocity bullets
  10. We also noticed complications in patients who were initially treated by traditional bone setters (TBS) for fractures resulting from gunshot wounds. These included tetanus, gas gangrene and vascular gangrene of limbs that lead to death of the patients or amputation. Even those that reported early to the hospital opted for TBS treatment of their fractures against medical advice once they were stabilized
  11. Few of the patients had surgeries ranging from laparatomies, amputations and neck wound repairs in the main theater. Wound debridement's were done A and E theater.
Figure 1: (a) Sex distribution, (b) Sex distribution, (c) Categories of people injured, (d) Causes of injury

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1223 (91.3%) were males, and 116 (8.9%) were females. Gunshot accounted for 1229 (91.8%) of the injuries, followed by bomb blast 90 (6.7%), knife (Cut throat) 4 (0.3%), road traffic accident 1 (0.1%) and others 15 (1.1%). Casualties were made up of civilians 1144 (85.4%), a joint task force (JTF) (a force made up of the Military, Police, Customs, and Immigration against the insurgents) 117 (8.7%), and insurgents 22 (1.6%). The ages ranged from 1 year to 80 years, (peaking at the age range 21-40 years, 796 [59.4%]).

It is disheartening to know that no authentic figure of those killed available anywhere. Vanguard of December 1, 2012 puts the death toll at over 4000 between 2009 and that date. In 2013, it reported a death toll of over 1000. This included civilians, JTF and vigilantes (Civilian JTF). The last group is made up of youths and young men who formed a resistant group to fight the Boko Haram, which helped to save more lives in villages and towns than the JTF did. In fact, the people came to trust them more than they did the JTF. Number of insurgents killed if known, will be staggering. This shows only a handful of all victims within the period under review made it to the hospital alive, where few more were lost.

From records available to us, the lower limbs were most injured 467 (39.9%), followed by the upper limbs 267 (19.9%), then abdomen 164 (12.2%), chest 50 (11.2%), pelvis and perineum 109 (8.1%), multiple injuries 93 (6.9%) and head and neck 89 (6.6%). All injuries and wounds were open.

We reviewed the cause of death of the 113 that died and found that 31 (27.4%) died from penetrating chest injuries, 30 (26.5%) from penetrating abdominal injuries, 22 (19%), multiple injuries 15 (13.3%), pelvis 8 (7%) and lower limbs 6 (5.3%), due to massive blood loss and infections, from head and neck injuries due to fatal wounds, and severe burns from bomb blast 1 (0.9%). Bomb blast resulted in thermal burns [5] and one of the patients who sustained 90% burns died. Most of the victims of the bomb blast had temporary hearing impairment, and one of them had both eyeballs blown out of their sockets leading to permanent blindness.

   Discussion Top

From the case notes, we noted that there was the lack of hospital consumables like intravenous fluids, bandages, antibiotics to adequately treat the victims. For example, there were no external fixators (EX-FIX) for the open limbs fractures, which are mostly type III [4],[6],[7],[8] and Foley Catheter was used for draining the chest after thoracostomies and EX-FIX were improvised for complex limb injuries from bomb blasts [Figure 2]a-f and most limb fractures.
Figure 2: (a-e) Modified external fixators (f) improvised chest tube

Click here to view

Limited Intensive Care Units beds (8 in total) and less 10 trained staff, for critical patients, especially those with penetrating and blast lung injuries, [9] contributed to more deaths. It is of concern that the materials used for the IEDs are easily available locally since they are spelt out on the internet. [10] Whenever there are terrorists' attacks, the types of injuries are diverse, and all health facilities must prepare for anything. [11]

Most of the patients' case notes were still with the finance department where we were given access, due nonpayment of their hospital bills by the state government or the JTF. This really put a financial strain on the hospital making it more di1fficult for other victims to be treated. This definitely affected the management of these cases.

   Conclusion Top

Injuries resulting from terrorists' activities can be overwhelming. The Management, Doctors and medical staff at the UMTH have so far done well with the limited resources available to them, but there is need to improve on the preparedness of the hospital in terms of facilities and personnel to manage these injuries.

   Acknowledgmwnts Top

We are grateful to the staff of the accident and emergency Department of the UMTH for good record keeping, the Health Information Department, the theatre and ward staff where most of the patients were managed. Finally, we want to thank Miss Patricia Edward of Borno Orthopedic Center Maiduguri for the secretarial work.

   References Top

Definitions of Terrorism. United Nations Office on Drugs and Crime; October 17, 2005. Available from: http// . [Last accessed on 2014 Apr 30].  Back to cited text no. 1
Improvised Explosive Devices (IEDs)/Booby Traps. Global; October17, 2005. Available from: http// . [Last accessed on 2014 Apr 30].  Back to cited text no. 2
Stein M, Hirshberg A. Medical consequences of terrorism. The conventional weapon threat. Surg Clin North Am 1999;79:1537-52.  Back to cited text no. 3
French B, Tometta P. Treatment of complex fractures: High energy tibial shat fractures. Clin Orthop 2002;33:1-24.  Back to cited text no. 4
Singer P, Cohen JD, Stein M. Conventional terrorism and critical care. Crit Care Med 2005;33:S61-5.  Back to cited text no. 5
Henley MB, Chapman JR, Agel J, Harvey EJ, Whorton AM, Swiontkowski MF. Treatment of type II, IIIA, and IIIB open fractures of the tibial shaft: a prospective comparison of unreamed interlocking intramedullary nails and half-pin external fixators. J Orthop Trauma 1998;12:1-7.  Back to cited text no. 6
Shaw DL, Lawton JO. External fixation for tibial fractures: clinical results and cost effectiveness. J R Coll Surg Edinb 1995;40:344-6.  Back to cited text no. 7
Checketts RG, Young CF. External fixation of diaphyseal fractures. Curr Orthop 2003;17:10-7.  Back to cited text no. 8
Halpern P, Tsai MC, Arnold JL, Stok E, Ersoy G. Mass-casualty, terrorist bombings: implications for emergency department and hospital emergency response (Part II). Prehosp Disaster Med 2003;18:235-41.  Back to cited text no. 9
Commerce in explosives; list of explosive material. Bureau of Alcohol, Tobacco and Firearms. ATF; October 17, 2005. Available from: http// [Last accessed on 2014 Apr 28].  Back to cited text no. 10
Peleg K, Aharonson-Daniel L, Michael M, Shapira SC, Israel Trauma Group. Patterns of injury in hospitalized terrorist victims. Am J Emerg Med 2003;21:258-62.  Back to cited text no. 11


  [Figure 1], [Figure 2]

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