BACKGROUND:
Conflict-related disruption of transport, referral, and surgical capacity can delay trauma care and increase avoidable complications that translate into long-term disability. Evidence in open extremity injuries consistently links delays—particularly delayed antibiotic prophylaxis and delayed definitive care—to higher infection and reoperation risk, which are major drivers of disability.

METHODS:
We performed a retrospective cohort study of limb trauma patients treated at a major referral hospital in the West Bank, Palestine, from January 2022 to December 2024. The exposure was time-to-care, defined as injury-to-hospital arrival and analyzed in categories (<2 hours, 2–6 hours, >6 hours). The primary outcome (“preventable disability”) was a composite of deep surgical site infection within 90 days, unplanned reoperation, or secondary amputation. Multivariable logistic regression estimated adjusted odds ratios (aORs) controlling for age, sex, injury mechanism, open fracture status (Gustilo grade where available), transfer status, and diabetes.

RESULTS:
Of 487 patients (median age 28 years; 73% male), 29% arrived within <2 hours, 41% within 2–6 hours, and 30% after >6 hours. The primary outcome occurred in 14.2% overall. Compared with <2 hours, arrival at 2–6 hours was associated with higher odds of preventable disability (aOR 1.58, 95% CI 1.00–2.50), and arrival at >6 hours showed a stronger association (aOR 2.74, 95% CI 1.68–4.47). Among open fractures (n=198), antibiotic administration >2 hours after emergency department presentation was associated with increased infection risk (aOR 2.10, 95% CI 1.15–3.83).

CONCLUSIONS:
Delayed time-to-care was associated with avoidable complications that plausibly contribute to disability after limb trauma in this conflict-affected setting. Strengthening time-critical referral pathways, early antibiotics for open fractures, and protected operating capacity are actionable equity-focused priorities.