Comparative outcomes of timely versus delayed presentation of pediatric fractures in post-conflict Iraq: a multicenter retrospective cohort study

Objective: This study aimed to determine the prevalence and outcomes of delayed fracture presentation in Iraq children and to identify predictors of delay, with a novel focus on the compounding effects of geography, referral pathways, and displacement status.

Methods: This retrospective, multicenter cohort study was conducted at three pediatric orthopedic referral centers in Iraq (Baghdad, Najaf, Mosul) from 2019-2024. 858 children (<16 years) with acute long bone fractures were included. The primary exposure was delayed presentation (≥7 days after injury). Multivariable logistic regression was used to identify predictors. Interaction (cascade of vulnerability) and stratified analyses were performed to assess the combined effects of barriers and the modifying role of displacement status (internally displaced person [IDP] vs. non-displaced).

Results: Delayed presentation occurred in 36.0% (n = 309) of children. After adjusting for confounders, including operative vs. nonoperative treatment, delay remained independently associated with significantly higher odds of malunion (AOR 3.20), nonunion (AOR 2.65), reoperation (AOR 2.45), and functional limitation (AOR 3.15). A synergistic “cascade of vulnerability” was observed: rural children who were referred had nearly six-fold higher odds of delay compared to urban, directly presenting children (AOR 5.9, 95% CI 4.0 8.7). Displacement status was a significant effect modifier; while rural residence strongly predicted delay in non-displaced children, this association vanished for IDPs, where referral inefficiency became the sole dominant barrier regardless of location. Among non-displaced children, both rural residence (AOR 2.7) and referral (AOR 2.1) were strong predictors. For IDPs, rural residence was no longer significant (P = .36), while referral from another facility emerged as the dominant barrier (AOR 3.4, 95% CI 1.5-7.7).

Conclusion: In Iraq, delayed treatment for children’s fractures is a common and serious issue strongly associated with systemic healthcare vulnerabilities and humanitarian challenges. Children in rural areas and those who are internally displaced are particularly at risk. For displaced children, difficulties navigating the healthcare system represent a more prominent risk factor than geographic distance. The findings highlight a need to strengthen the health system and provide tailored support for displaced populations to ensure all children receive timely care for fractures.

Cite this article as: Jameel M, Alzubaidi AA, Jamel WA, Alkurdi BB. Comparative outcomes of timely versus delayed presentation of pediatric fractures in post-conflict Iraq: A multicenter retrospective cohort study. Acta Orthop Traumatol Turc., 2026; 60(5), 0900, doi: 10.5152/j.aott.2026.26900.