Natural disasters are unexpected occurrences that can result in destruction and heavy casualties [1,2], and earthquakes are likely to have the greatest negative impact on human health among them. Growing populations have increased the need for living spaces, especially in cities, thereby putting individuals in a riskier position against earthquakes in developing countries. On February 6, 2023, two earthquakes (moment magnitudes of 7.8 and 7.6) with a 9-hour interval struck southern Turkey and western Syria. At present, they are the strongest “doublet” earthquakes ever recorded in the Levant [3]. The impact on mortality (fifth deadliest of the 21st century) and costs (fourth costliest) was catastrophic [4]. As an interesting side note, the occurrence of these earthquakes in this region is also believed to be a sign of the apocalypse. Likewise, the great battle (Armageddon) is also expected to take place in this zone.

From a medical perspective, physicians need to tackle various neuromusculoskeletal conditions and their complications (e.g., fracture, crush injury, amputation, compartment syndrome, and nerve lesions) after earthquakes. In addition to the well-established role of physiatrists in the long-term rehabilitation of pertinent cases, the medical services provided to these patients can notably be upgraded with the prompt and convenient use of ultrasound (US) examination. US can play a key role in diagnosing soft tissue and peripheral nerve lesions in posttraumatic conditions. Some exemplary findings would include focal nerve/fascicular enlargement, loss of internal fascicular structure, nerve discontinuity, and increased cross-sectional area of the nerve in nerve injuries [5]. Traumatic muscles can show signs of swelling with or without focal/general areas of increased echogenicity (muscle strain), hypo/hyperechogenic appearance with or without fibrillar discontinuity (muscle contusion), hypoechoic or anechoic circumscribed lesions (muscle hematoma), and muscle atrophy [6,7]. Sono-Tinel, a probe compression that causes pain on the pathological side, is also suggestive of these lesions [8]. To this end, also being aware of the mounting utility of US in physiatry, we considered that a pictorial essay summarizing our recent experience with the Kahramanmaraş earthquake would help to exemplify its actual contribution to disaster relief. In particular, we tried to render how US examination impacted our medical approach to nerve/muscle injuries.

Hacettepe University Hospital is a tertiary referral center that has treated earthquake survivors. A total of 52 individuals—who were consulted from different in-patient services or who applied to our outpatient clinic—were examined. Table 1 summarizes the clinical features and treatment methods used. Earthquake survivors who had been examined in our department between February 13, 2023 and April 4, 2023 were included, and pertinent data were collected between April 5, 2023 and April 29, 2023.

After a complete physical examination (orthopedic examination of all involved joints and their adjacent joints and neurological examination including muscle strength, light touch sensation, pain sensation, deep tendon reflexes, and pathological reflex examinations), all patients were also evaluated for various nerve/muscle injuries by US examination. Six patients were scanned using a 5 to 12 MHz linear transducer (GE Logiq P5, Madison, WI, USA), and a portable device with a linear transducer (4–13 MHz, Clarius L7; Clarius Mobile Health, Vancouver, BC, Canada) was used for the remaining cases.

The mean age of the patients was 29.4±19.4 years (range, 7–72 years). The mean duration of being trapped under rubble was 28.6±30.4 hours (range, 4–120 hours). Nineteen patients had peripheral nerve involvement, including four brachial plexuses, one lumbosacral plexus, and 17 limb nerve injuries (the peroneal nerve being the most affected) (Table 1). The characteristic ultrasonographic findings of earthquake victims with nerve/muscle injuries are summarized in Table 2. Electrodiagnostic studies were not performed because the patients had skin lesions such as abrasion and edema or were bandaged. Magnetic resonance imaging (MRI) for plexopathy was performed in five patients. The remaining patients were diagnosed with peripheral nerve entrapment based on physical and ultrasonographic examinations. Of the 52 patients, six who had demonstrative/exemplary imaging findings were selected for this study. They are further discussed in detail, with a special focus on the US findings.

US is a simple, fast, and inexpensive examination method that plays an important role in the management of traumatic peripheral nerve/muscle injuries [9,10]. Owing to its portability, not only in routine daily practice but also in several settings can it be applied in a convenient/effective way. Following our recent experience, we actually aim to extend the possibility―also to include its use “on-site.” In other words, physiatrists/physicians would be capable of contributing to the prompt triage of these patients. Needless to say, the spectrum of emergency pathologies that can be examined with US also comprises those of the cortical bone. As such, occult fractures can also be diagnosed simultaneously. Indeed, these fractures may be associated with lesions in the surrounding peripheral nerves or soft tissues/muscles. Discontinuity of the hyperechoic cortical bone and hypoechoic subperiosteal hematoma are the major US findings in bone fractures in the acute phase [11].

Peripheral nerves can be injured by mechanical compression, ischemia, or direct trauma [12]. While the diagnosis can already be challenging enough in daily routine, an earthquake scenario definitely adds up to the difficulty of diagnosis. Yet, the complexity of the trauma (compartment syndrome, fasciotomy, fractures, amputation, etc.) and the accompanying medical conditions would contribute to this aspect. Additionally, electrodiagnosis is either impossible or has limited use in these patients. Of note, the other (magnetic resonance) imaging option is again not applicable for several simple reasons. On the contrary, the flexible use of the US transducer provides access to different regions regardless of the patient’s position/condition. Scanning throughout their entire course, peripheral nerves as well as the pertinent muscles can be examined both statically and dynamically, where appropriate. Nerve integrity, edema, partial/complete rupture, and the underlying cause of injury are examined in a comprehensive approach. In the management of earthquake survivors, US plays a paramount role in ensuring early and accurate diagnosis, facilitating the timely initiation of appropriate rehabilitation program, it encompasses a spectrum of interventions, including range of motion, strengthening and mobilization exercises where applicable, functional electrical stimulation of denervated muscles, orthoses/splints, prosthetic programs for patients with amputated limbs, and various physical therapy modalities for pain control [13]. US will also assist in the prompt implementation of tailored rehabilitation plans during follow-up. It is noteworthy that the patient-friendly nature of US indisputably helps the physician and the “already traumatized” patient alike. After precise diagnoses, physical therapy, interventions, or surgery can timely be applied. Lastly, US will also aid in closely monitoring the morphological changes during healing/treatment.