A Cross-Sectional Assessment of Orthopaedic Care Capacity in the Zaatari Refugee Camp

The Syrian conflict has displaced over 14 million people, including approximately 5.9 million registered refugees across the Middle East and North Africa[1]. Jordan hosts more than 650,000 Syrian refugees registered with the United Nations High Commissioner for Refugees (UNHCR), with roughly 80,000-100,000 residing in the Zaatari refugee camp[1]. Established in 2012, the Zaatari refugee camp in Jordan is one of the world’s largest refugee settlements, with a total of six full-time health centers[2].

Musculoskeletal conditions represent a significant and under-addressed health burden in this population. Refugees experience high rates of orthopaedic disease due to conflict-related trauma, road traffic injuries, congenital disorders, and chronic degenerative conditions[3–6]. Yet the capacity to provide surgical and rehabilitative orthopaedic services in refugee camps has not been systematically evaluated. Most published work focuses on infectious disease, maternal-child health, or mental health, leaving surgical and orthopaedic capacity insufficiently described[7–10].

The PIPES tool offers an established framework for describing surgical capacity in low-resource settings[10]. It has been applied in diverse low- and middle-income countries, including hospitals in sub-Saharan Africa, South America, and the Middle East[10–12]. However, it has not previously been applied to refugee camp settings, nor specifically adapted to orthopaedic surgery.

We therefore assessed orthopaedic care capacity across health facilities serving the Zaatari refugee camp using an adapted PIPES framework. By adapting the tool to emphasize musculoskeletal procedures, implants, and fracture management, we aimed to quantify available capacity and identify critical gaps.

Study design and setting
We conducted a cross-sectional capacity assessment in the Zaatari refugee camp in northern Jordan, one of the world’s largest Syrian refugee settlements with an estimated population of 80,000-100,000 people. Data collection was performed during a humanitarian visit in collaboration with the Syrian American Medical Society (SAMS) in April 2025.

Survey tool
We used a modified version of the Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) surgical assessment tool, originally developed by Surgeons OverSeas from the WHO situational analysis survey (Appendix). The original PIPES tool includes 105 binary items across five domains and has been validated in diverse low-resource settings. For this study, we adapted the tool to assess orthopaedic care capacity, emphasizing musculoskeletal services, fracture management, and trauma-related resources (Appendix). Although the original PIPES tool has been validated, this adapted orthopaedic version has not been independently validated. The tool is publicly available, no special permission was required for its use or adaptation, and the original source is cited.

Key modifications were as follows:

1. Personnel: Additional categories were added for orthopaedic surgeons and orthopaedic residents, while retaining the original categories of general surgeons, anaesthesiologists, medical doctors performing procedures, and nurse anaesthetists.
2. Procedures: The list of procedures was revised to include orthopaedic interventions such as fracture fixation techniques (external fixation, plating, intramedullary nailing, K-wire fixation, flexible nails for paediatric fractures), elective orthopaedic procedures (arthroplasty, arthroscopy, hand surgery, spine surgery, limb lengthening), and temporizing/emergency procedures (fasciotomy, traction, closed reduction of fractures and dislocations, steroid injections)[13]. General surgical and obstetric procedures not relevant to orthopaedic care (e.g., caesarean section, hysterectomy, laparotomy, hernia repair) were excluded.
3. Equipment: The equipment domain was refined to emphasize orthopaedic and trauma-specific resources, including fracture instrument sets, microsurgery sets, and arthroscopes, while excluding non-orthopaedic instruments such as vaginal specula and endoscopes[14,15].
4. Supplies: The supply list was modified to incorporate orthopaedic implants and consumables, including plates and screws, intramedullary nails, external fixators, and casting/splinting materials. Supplies specific to non-orthopaedic surgery (e.g., urinary catheters, laparoscopic supplies, chest tubes) were excluded[13–15].

Although item content was modified, the adapted instrument preserved the original 105-item scoring structure through one-for-one substitution of orthopaedic-relevant items for less relevant general surgical or obstetric items. The modified tool retained the original binary scoring system: infrastructure, equipment, and supplies were scored as “always available” (1) or “not always available” (0), while procedures were scored as “done” (1) or “not done” (0). Personnel were recorded as absolute numbers.

Participants and data collection
The research team consisted of two medical students, two medical doctors, one dual board-certified orthopaedic surgeon with paediatric and hand subspecialty training, and a data analyst. The facilities visited included the International Medical Corps (IMC) emergency department, International Rescue Committee (IRC) clinic, Qatar Red Crescent (QRC) clinic, Arab Medical Relief (AMR) clinic, and Syrian American Medical Society (SAMS) clinic. All interviews were conducted in person using the structured survey instrument. At each facility, the interviewee was the clinician or administrator most knowledgeable about available services, procedures, equipment, and supplies. When available, orthopaedic surgeons were included in the interview.

Responses were reviewed in real time by the research team, and clarification questions were asked when answers were ambiguous or appeared inconsistent with available infrastructure. For example, if a procedure was initially reported as available, interviewers asked whether it was performed on site, whether anaesthesia or procedural sedation was available, and whether the necessary equipment and supplies were present. Discrepant responses were resolved through follow-up questioning during the same visit. When a procedure was initially reported but later clarified to represent immobilization or splinting rather than true reduction or operative treatment, the more conservative interpretation was used for scoring and reporting.

Scoring and analysis
Domain scores were calculated as follows:

• Personnel (P): total number of providers in each personnel category.
• Infrastructure (I): number of infrastructure items available (maximum 13) plus number of functioning operating rooms.
• Procedures (Pr): number of procedures reported as performed on-site (maximum 40).
• Equipment (E): number of essential equipment items available (maximum 22).
• Supplies (S): number of consumable supply items available (maximum 25).

The total PIPES score was calculated as the sum of all domain scores. Because the adapted instrument preserved the original 105-item scoring structure, we calculated a PIPES index using the same scaling approach as the original PIPES framework, dividing each facility’s total score by 105 and multiplying by 10. Given that the instrument was modified, these indices should be interpreted as exploratory facility-level summaries rather than directly comparable validated PIPES scores. Higher indices were intended to reflect relatively greater facility-level orthopaedic care capacity.

Ethics
This was an observational facility-level assessment with no patient-level data collected. Verbal consent was obtained from all interviewees prior to survey administration. The project was reviewed by the Dartmouth College Institutional Review Board and determined to be exempt from formal review as it did not constitute human subjects research.

The surveyed sites represented five of six full-time health facilities in the Zaatari refugee camp. All facilities were visited in person, and data were obtained from clinic managers, managing physicians, and, when available, orthopaedic surgeons.

Facility characteristics
The four outpatient clinics, SAMS, IRC, QRC, and AMR, reported no inpatient beds or operating theatres. The IMC emergency department reported 22 inpatient beds but no functioning operating theatre.

Personnel
Two part-time volunteer orthopaedists were identified, one at the IRC clinic and one at the AMR clinic. No facility reported an anaesthesiologist or nurse anaesthetist. General physicians performed most available procedures. Personnel scores ranged from 1 to 10, with a mean of 5.0.

Infrastructure
Running water, electricity, and basic laboratory services were consistently available. No facility reported an operating theatre, intensive care unit, blood bank, or computed tomography imaging. Functional X-ray capability was reported at two facilities, and ultrasound was available at four. Infrastructure scores ranged from 5 to 8, with a mean of 6.6.

Procedures
All facilities reported minor wound care procedures, including suturing, debridement, and incision and drainage. Two clinics initially reported the ability to perform closed reduction, but this was later clarified as in-situ immobilization and splinting rather than true reduction. No facility reported intramedullary nailing, plate fixation, arthroplasty, spine surgery, fasciotomy, or skeletal traction. Steroid injections were reported only at the AMR and IRC clinics. Procedure scores ranged from 3 to 11, with a mean of 7.0.

Equipment
Basic resuscitative and monitoring equipment, including oxygen, bag-mask ventilation devices, pulse oximeters, autoclaves, and suction pumps, were variably available. Advanced surgical equipment, including anaesthesia machines, arthroscopes, and microsurgery sets, was absent across all facilities. Equipment scores ranged from 9 to 16, with a mean of 12.2.

Supplies
Basic consumables, including sterile gloves, intravenous fluids, cannulas, syringes, and suture materials, were consistently available. Orthopaedic implants, including plates, screws, intramedullary nails, and external fixators, were not available at any facility. Supplies scores ranged from 16 to 22, with a mean of 18.0.

Adapted PIPES indices
Adapted PIPES indices ranged from 3.71 to 5.71 across Zaatari facilities, with a mean of 4.87 (Table 1). The AMR clinic had the highest index, while the SAMS and QRC clinics had the lowest indices.

This study provides the first systematic assessment of orthopaedic care capacity within the Zaatari refugee camp. Using an adapted PIPES framework, we found that camp-based facilities had basic capacity for wound care, splinting, and limited outpatient orthopaedic services, but no on-site operative orthopaedic capability. Adapted PIPES indices ranged from 3.7 to 5.7 across surveyed facilities, consistent with the broader descriptive finding of severely constrained orthopaedic care. Because the PIPES tool was modified for this study and has not been validated in its adapted form, these scores should be interpreted as exploratory facility-level summaries rather than validated measures of surgical capacity or direct comparisons with prior PIPES studies.

Gaps in orthopaedic care
The deficits identified were fundamental. None of the facilities in Zaatari had a functioning operating theatre, theatre lights, or anaesthesia machine, and none employed anaesthesia providers. As a result, no operative orthopaedic procedures could be delivered. Temporizing measures such as skeletal traction were also unavailable. Essential fracture instrument sets and implants including plates, screws, intramedullary nails, and external fixators were absent, eliminating the possibility of definitive stabilization for long bone or periarticular fractures. Urgent limb-saving procedures such as fasciotomy for compartment syndrome were likewise not performed.

Non-operative management was also limited. There was no reliable access to closed reductions of fractures in adults or children, and no paediatric cast application. The bulk of fracture care consisted of in-situ plaster splinting. Minor procedures under local anaesthesia, such as abscess incision and drainage, were performed, but no other wide-awake interventions such as carpal tunnel release, trigger finger release, or ganglion cyst excision were available. Steroid injections were inconsistently offered. Rehabilitation services were minimal, with limited physical therapy and no dedicated hand therapy.

Soft-tissue and infection management capacity was constrained. Skin grafting, contracture release, and amputations were unavailable, while medical osteomyelitis management was reported at only one site. Imaging was inconsistent: two clinics reported functional X-ray machines, while none had CT. Intensive care and blood banking were absent, restricting the safety of any operative activity. In practice, care was limited to splinting, wound care, and occasional procedures without reliable procedural anaesthesia. For patients with displaced fractures, open injuries, or vascular compromise, these limitations may increase the risk of delayed or incomplete treatment and could contribute to malunion, chronic pain, or disability, although these outcomes were not directly measured in this study[16–19].

Comparison with prior work
Our findings are consistent with regional assessments showing limited surgical capacity in refugee-affected settings. In Lebanon, the SCAR study demonstrated that UNHCR-affiliated hospitals possessed surgical capacity comparable to non-affiliated institutions, though geographic mismatches restricted access for refugees[10]. Zaatari differs fundamentally: its clinics and emergency department were not designed to provide surgery, leaving residents dependent on referral to external hospitals. Similar deficits in fracture fixation and implant availability have been reported in Turkiye, Syria, and Lebanon but our study demonstrates that within Zaatari itself, operative capacity was absent, and non-operative orthopaedic capacity for both trauma and elective care was limited[7,10,20–23].

Implications for system design
The absence of on-site orthopaedic surgery in Zaatari has important implications for how patients with urgent musculoskeletal conditions must access care. In general, delayed access to fixation, fasciotomy, or other limb-saving procedures may increase the risk of preventable morbidity, including malunion, chronic pain, functional limitation, and limb loss. For children, untreated deformity or neglected clubfoot can lead to lifelong functional limitation[24–26]. From a global surgery perspective, orthopaedic equivalents of the bellwether procedures such as fracture fixation, fasciotomy, and amputation cannot be performed within the camp[27]. These findings suggest that strengthening orthopaedic care for Zaatari residents will likely require attention to both referral systems and selected camp-based services. Because this study did not measure referral completion, treatment delays, clinical outcomes, or the burden of untreated disease, we cannot determine from these data how often patients fail to receive needed operative care after referral. However, the absence of operative infrastructure within the camp indicates that patients with displaced fractures, open injuries, compartment syndrome, or other limb-threatening conditions are necessarily dependent on external hospitals. Future work should evaluate referral pathways, transport availability, financial coverage, treatment delays, and patient outcomes in greater detail to help determine whether investment should prioritize strengthened referral pathways or expanded visiting specialist services and the development of a limited camp-based operative package[13,15,28–30].

Limitations
This study has several limitations. First, the adapted PIPES tool has not been validated in this modified form. We therefore emphasize domain level findings and specific service gaps rather than the absolute index values. Second, responses were based on interviews with facility staff and may be subject to respondent bias, social desirability bias, or differences in interpretation of what constituted an available procedure or service. To reduce this risk, interviewers asked clarification questions during each facility visit and used conservative scoring when responses were ambiguous. Third, the assessment measured reported facility capacity at a single time point and did not measure referral completion, referral delays, surgical volume, patient outcomes, or the burden of untreated orthopaedic disease. Finally, one of the six full-time Zaatari health facilities was not assessed.

Zaatari health facilities demonstrated severely limited orthopaedic care capacity, with no on-site operative capability across all surveyed sites. Facilities had basic capacity for wound care, immobilization, and limited outpatient orthopaedic services, but operating rooms, anaesthesia services, blood banking, intensive care capacity, fracture instrumentation, and orthopaedic implants were absent. These results highlight critical gaps in camp-based orthopaedic service capacity and support future work in improving orthopaedic care for refugees.