Skip to main content

Advertisement

SpringerLink
Log in

Ballistic peripheral nerve injuries: basic concepts, controversies, and proposal for a management strategy

  • Review Article
  • Published:
European Journal of Trauma and Emergency Surgery Aims and scope Submit manuscript

Abstract

Ballistic injuries to peripheral nerves are devastating injuries frequently encountered in modern conflicts and civilian trauma centers. Such injuries often produce lifelong morbidity, mainly in the form of function loss and chronic pain. However, their surgical management still poses significant challenges concerning indication, timing, and type of repair, particularly when they are part of high-energy multi-tissue injuries. To help trauma surgeons, this article first presents basic ballistic concepts explaining different types of missile nerve lesions, described using the Sunderland classification, as well as their usual associated injuries. Current controversies regarding their surgical management are then described, including nerve exploration timing and neurolysis’s relevance as a treatment option. Finally, based on anecdotal evidence and a literature review, a standardized management strategy for ballistic nerve injuries is proposed. This article emphasizes the importance of early nerve exploration and provides a detailed method for making a diagnosis in both acute and sub-acute periods. Direct suturing with joint flexion is strongly recommended for sciatic nerve defects and any nerve defect of limited size. Conversely, large defects require conventional nerve grafting, and proximal injuries may require nerve transfers, especially at the brachial plexus level. Additionally, combined or early secondary tendon transfers are helpful in certain injuries. Finally, ideal timing for nerve repair is proposed, based on the defect length, associated injuries, and risk of infection, which correlate intimately to the projectile velocity.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

adapted from Giannou and Baldan [23]. Shooting channel of a non-deforming low-velocity bullet shows little yaw and no tumbling: the temporary cavity is long and narrow without significant shock wave effect (upper). The shooting channel of a non-deforming high-velocity bullet typically presents three phases (lower): narrow straight channel (phase 1), large temporary cavity related to the shock wave effect (phase 2), and narrow end channel (phase 3). In this case, the temporary cavitation is due to spontaneous projectile tumbling after a 15 cm straight channel. If this bullet had exited the target before 15 cm, no tumbling and no shock wave effect would have been noticed. Take note that many other parameters can affect these theorical schemes, such as projectile destabilization by external barriers or bones, projectile deformation, and fragmentation

Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8

Similar content being viewed by others

References

  1. Stewart MPM, Birch R. Penetrating missile injuries of the brachial plexus. J Bone Joint Surg Br. 2001;83:B517–24.

    Article  Google Scholar 

  2. Bhandari PS, Sadhotra FP, Bhargava P, Bath AS, Mukherjee MK, Singh P, et al. Management of missile injuries of the brachial plexus. IJNT. 2006;3:49–54.

    Article  Google Scholar 

  3. Stoebner AA, Sachanandani NS, Borschel GH. Upper and lower extremity nerve injuries in pediatric missile wounds: a selective approach to management. Pediatr Surg Int. 2011;27:635–41.

    Article  PubMed  Google Scholar 

  4. Birch R, Eardley WGP, Ramasamy A, Brown K, Shenoy R, Anand P, et al. Nerve injuries sustained during warfare. Part I—Epidemiology. J Bone Joint Surg Br. 2012;94B:523–8.

    Article  Google Scholar 

  5. Birch R, Misra P, Stewart MPM, Eardley WGP, Ramasamy A, Brown K, et al. Nerve injuries sustained during warfare: part II—outcomes. J Bone Joint Surg Br. 2012;94B:529–35.

    Article  Google Scholar 

  6. Chambers JA, Hiles CL, Keene BP. Brachial plexus injury management in military casualties: who, what, when, why, and how. Mil Med. 2014;179:640–4.

    Article  PubMed  Google Scholar 

  7. Rivera JC, Glebus GP, Cho MS. Disability following combat-sustained nerve injury of the upper limb. Bone Joint J. 2014;96B:254–8.

    Article  Google Scholar 

  8. Rochkind S, Strauss I, Shlitner Z, Alon M, Reider E, Graif M. Clinical aspects of ballistic peripheral nerve injury: shrapnel versus gunshot. Acta Neurochir (Wien). 2014;156:1567–75.

    Article  Google Scholar 

  9. Pannell WC, Heckmann N, Alluri RK, Sivasundaram L, Stevanovic M, Ghiassi A. Predictors of nerve injury after gunshot wounds to the upper extremity. Hand. 2017;12:501–6.

    Article  PubMed  Google Scholar 

  10. Masmejean E, Bihel T, Lafosse T, Pierrart J, Silvera J, Mir O, Gregory TM. Bataclan’s ulnar nerve syndrome. Am J Med. 2017;130:e105–6.

    Article  PubMed  Google Scholar 

  11. Rasulić L, Simić V, Savić A, Lepić M, Kovačević V, Puzović V, et al. Management of brachial plexus missile injuries. Acta Clin Croat. 2018;57(3):487–96.

    PubMed  PubMed Central  Google Scholar 

  12. Jones PE, Meyer M, Faillace WJ, Landau ME, Smith JK, McKay PL, et al. Combat injury of the sciatic nerve—an institutional experience. Mil Med. 2018;183:e434–41.

    Article  PubMed  Google Scholar 

  13. El Hadj AY, Beveridge J, Chan M, Deeb T, Mowafi H, Al-Nuaimi S, et al. Devastating neurologic injuries in the Syrian war. Neurol Clin Pract. 2019;9:9–15.

    Article  Google Scholar 

  14. Mathieu L, Alqassab S, Fakhi RM. Sniper-induced sciatic nerve injury. BMJ Mil Health. 2020;166:210.

    Article  PubMed  Google Scholar 

  15. Iordache SD, Gorski A, Nahas M, Feintuch L, Rahamimov N, Rutenberg TF. Treatment of peripheral nerve injuries in Syria’s war victims: experience from a northern Israeli hospital. Isr Med Assoc J. 2021;23:279–85.

    PubMed  Google Scholar 

  16. Guedes F, Sanches GE, Novaes N, Guimarães Ferreira A, Torrão F. Surgical management of pediatric patients with peripheral nerve and plexus lesions caused by stray bullets. Childs Nerv Syst. 2021;37:1219–27.

    Article  PubMed  Google Scholar 

  17. Straszewski AJ, Schultz K, Dickherber JL, Dahm JS, Wolf JM, Strelzow JA. Gunshot-related upper extremity injuries at a level 1 trauma center. J Hand Surg Am. 2021. https://doi.org/10.1016/j.jhsa.2021.03.020.

    Article  PubMed  Google Scholar 

  18. Wang E, Inaba K, Byerly S, Escamilla D, Cho J, Carey J, et al. Optimal timing for repair of peripheral nerve injuries. J Trauma Acute Care Surg. 2017;83:875–81.

    Article  PubMed  Google Scholar 

  19. MacKay BJ, Cox CT, Valerio IL, Greenberg JA, Buncke GM, Evans PJ, et al. Evidence-based approach to timing of nerve surgery: a review. Ann Plast Surg. 2021;87:e1-21.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Jandial R, Reichwage B, Levy M, Duenas V, Sturdivan L. Ballistics for the neurosurgeon. Neurosurgery. 2008;62:472–80.

    Article  PubMed  Google Scholar 

  21. Secer H, Daneyemez M, Tehli O, Gonul E, Izci Y. The clinical, electrophysiological, and surgical characteristics of peripheral nerve injuries caused by gunshot wounds in adults: a 40-year experience. Surg Neurol. 2008;69:143–52.

    Article  PubMed  Google Scholar 

  22. Mathieu L, Bertani A, Gaillard C, Chaudier P, Ollat D, Bauer B, Rigal S. Surgical management of combat-related upper extremity injuries. Chir Main. 2014;33:174–82.

    Article  CAS  PubMed  Google Scholar 

  23. Giannou C, Baldan M. Mechanisms of injury during armed conflict. In: War surgery: working with limited resources in armed conflict and other situations of violence. Volume 1, 2nd edition. Geneva: ICRC; 2019. pp.55–80.

  24. Sunderland S. A classification of peripheral nerve injuries producing loss of function. Brain. 1951;74:491–516.

    Article  CAS  PubMed  Google Scholar 

  25. Oberlin C, Rantissi M. Gunshot injuries to the nerves. Chir Main. 2011;30:176–82.

    Article  CAS  PubMed  Google Scholar 

  26. Farber SJ, Saheb-Al-Zamani M, Zieske L, Laurido-Soto O, Bery A, Hunter D, et al. Peripheral nerve injury after local anesthetic injection. Anesth Analg. 2013;117:731–9.

    Article  CAS  PubMed  Google Scholar 

  27. Pfister G, de Carbonnières A, Dubourg O, Prat N, Cremades A, Mathieu L. Nerve injuries from gunshot wounds: what are the microscopic lesions on the continuous part of the partial sections? Hand Surg Rehabil. 2018;37:384–5.

    Article  Google Scholar 

  28. Bercik MJ, Kingsbery J, Ilyas AM. Peripheral nerve injuries following gunshot fracture of the humerus. Orthopedics. 2012;35:e349–52.

    Article  PubMed  Google Scholar 

  29. Akhavan-Sigari R, Mielke D, Farhadi A, Rohde V. Study of radial nerve injury caused by gunshot wounds and explosive injuries among Iraqi soldiers. J Med Sci. 2018;6:1622–6.

    Google Scholar 

  30. Kline DG, Kim D, Midha R, Harsh C, Tiel R. Management and results of sciatic nerve injuries: a 24-year experience. J Neurosurg. 1998;89:13–23.

    Article  CAS  PubMed  Google Scholar 

  31. Korompilias AV, Payatakes AH, Beris AE, Vekris MD, Afendras GD, Soucacos PN. Sciatic and peroneal nerve injuries. Microsurgery. 2006;26:288–96.

    Article  PubMed  Google Scholar 

  32. Boyd KU, Fox IK. Nerve repair and grafting. In: Mackinnon SE, editor. Nerve surgery. New York: Thieme Medical Publishers; 2015. p. 75–100.

    Google Scholar 

  33. Samardzić MM, Rasulić LG, Vucković CD. Missile injuries of the sciatic nerve. Injury. 1999;30:15–20.

    Article  PubMed  Google Scholar 

  34. Kim DH, Murovic JA, Tiel R, Kline DG. Management and outcomes in 353 surgically treated sciatic nerve lesions. J Neurosurg. 2004;101:8–17.

    Article  PubMed  Google Scholar 

  35. Nulsen FE, Slade WW. Recovery following injury to the brachial plexus. In: Woodhal BG, ed. Peripheral nerve regeneration. A follow-up study of 3656 World War II injuries. Washington, DC: Government Printing Office; 1956:389–408.

  36. Gousheh J, Arasteh E, Beikpour H. Therapeutic results of sciatic nerve repair in Iran-Iraq War casualties. Plast Reconstruct Surg. 2008;121:878–86.

    Article  CAS  Google Scholar 

  37. Saito H, Dahlin LB. Expression of ATF3 and axonal outgrowth are impaired after delayed nerve repair. BMC Neurosci. 2008. https://doi.org/10.1186/1471-2202-9-88.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Jonsson S, Wiberg R, McGrath A, Novikov LN, Wiberg M, Novikova LN, et al. Effect of delayed peripheral nerve repair on nerve regeneration, Schwann cell function and target muscle recovery. PLoS ONE. 2013;8:e56584.

    Article  Google Scholar 

  39. Pan D, Mackinnon SE, Wood MD. Advances in the repair of segmental nerve injuries and trends in reconstruction. Muscle Nerve. 2020;61:726–39.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Samadian M, Rezaee O, Haddadian K, Sharifi G, Abtahi H, Hamidian M, et al. Gunshot injuries to the brachial plexus during wartime. Br J Neurosurg. 2009;23:165–9.

    Article  PubMed  Google Scholar 

  41. Ferrante MA, Wiboum AJ. The electrodiagnostic examination with peripheral nerve injuries. In: SE Mackinnon eds. Nerve surgery. New York: Thieme Medical Publishers, Inc. New York. 2015; p.59–74.

  42. Holzgrefe RE, Wagner ER, Singer AD, Daly CA. Imaging of the peripheral nerve: concepts and future direction of magnetic resonance neurography and ultrasound. J Hand Surg Am. 2019;44:1066–79.

    Article  PubMed  Google Scholar 

  43. Smith JK, Miller ME, Carroll CG, Faillace WJ, Nesti LJ, Cawley CM, et al. High-resolution ultrasound in combat-related peripheral nerve injuries. Muscle Nerve. 2016;54:1139–44.

    Article  PubMed  Google Scholar 

  44. Nwawka OK, Casaletto E, Wolfe SW, Feinberg JH. Ultrasound imaging of brachial plexus trauma in gunshot injury. Muscle Nerve. 2019;59:707–11.

    Article  PubMed  Google Scholar 

  45. Roganovic Z. Missile-caused median nerve injuries: results of 81 repairs. Surg Neurol. 2005;63:410–8.

    Article  PubMed  Google Scholar 

  46. Mathieu L, Pfister G, Murison JC, Oberlin C, Belkheyar Z. Missile injury of the sciatic nerve: observational study supporting early exploration and direct suture with flexed knee. Mil Med. 2019;184:e937–44.

    Article  PubMed  Google Scholar 

  47. Mathieu L, Addas BMJ, Irimura SC, Oberlin C, Belkheyar Z. Management of sciatic nerve defects: lessons learned and proposal for a new strategy. Ann Plast Surg. 2020;84:559–64.

    Article  CAS  PubMed  Google Scholar 

  48. Bourrel P, De Bisschop G. Suture of the sciatic nerve performed 15 months after its section. Result 2 years later. Value of repeated exploration. Ann Chir. 1966;20:1145–9.

    CAS  PubMed  Google Scholar 

  49. Pfister G, Ghabi A, de Carbonnières A, Oberlin C, Belkheyar Z, Mathieu L. Direct suturing of sciatic nerve defects in high-degree knee flexion: an experimental study. World Neurosurg. 2020;133:e288–92.

    Article  PubMed  Google Scholar 

  50. Dunn JC, Tadlock J, Klahs KJ, Narimissaei D, McKay P, Nesti LJ. Nerve reconstruction using processed nerve allograft in the U.S. Military. Mil Med. 2021;186:e543–8.

    Article  PubMed  Google Scholar 

  51. Roganovic Z. Missile-caused ulnar nerve injuries: outcomes of 128 repairs. Neurosurgery. 2004;55:1120–9.

    Article  PubMed  Google Scholar 

  52. Kitta MI, Ariandi M, Nugroho YA, Nur A, Arden F. Neurological recovery across a 2-cm gap of radial nerve using end to end suture following supracondylar humerus fracture: case report. Int J Surg Case Rep. 2021. https://doi.org/10.1016/j.ijscr.2021.105896.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Rebowe R, Rogers A, Yang X, Kundu SC, Smith TL, Li Z. Nerve repair with nerve conduits: problems, solutions, and future directions. J Hand Microsurg. 2018;10:61–5.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Ducic I, Barrett DM, Al-Attar A. Benign peripheral nerve tumors: treatment algorithm and reconstructive options. Ann Plast Surg. 2009;63:156–61.

    Article  CAS  PubMed  Google Scholar 

  55. Bhandari PS, Deb P. Management of isolated musculocutaneous injury: comparing double fascicular nerve transfer with conventional nerve grafting. J Hand Surg Am. 2015;40:2003–6.

    Article  PubMed  Google Scholar 

  56. Brown JM, Yee A, Mackinnon SE. Distal median to ulnar nerve transfers to restore ulnar motor and sensory function within the hand: technical nuances. Neurosurgery. 2009;65:966–78.

    Article  PubMed  Google Scholar 

  57. Pages L, Le Hanneur M, Cambon-Binder A, Belkheyar Z. C5/C6 brachial plexus palsy reconstruction using nerve surgery: long-term functional. Orthop Traumatol Surg Res. 2020;106:1095–100.

    Article  PubMed  Google Scholar 

  58. Ucak M. Surgical restoration of drop-hand syndrome with tendon transfer in patients injured in the Syrian civil war. Mil Med Res. 2019;6:35.

    PubMed  PubMed Central  Google Scholar 

  59. Mathieu L, Achour S, Oberlin C, Belkheyar Z. Single versus double tendon transfer for foot drop due to post-traumatic common fibular nerve palsy. Eur J Trauma Emerg Surg. 2021. https://doi.org/10.1007/s00068-021-01602-6.

    Article  PubMed  Google Scholar 

  60. Vayvada H, Demirdöver C, Menderes A, Yilmaz M, Karaca C. The functional results of acute nerve grafting in traumatic sciatic nerve injuries. Ulus Travma Acil Cerrahi Derg. 2013;19:109–14.

    Article  PubMed  Google Scholar 

Download references

Funding

No source of funding.

Author information

Authors and Affiliations

  1. Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France

    Laurent Mathieu, Melody Goncalves, James Charles Murison & Georges Pfister

  2. French Military Hand Surgery Center, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France

    Laurent Mathieu, Melody Goncalves, James Charles Murison & Georges Pfister

  3. Department of Surgery, French Military Health Service Academy, Ecole du Val-de-Grâce, 1 place Alphonse Laveran, 75005, Paris, France

    Laurent Mathieu

  4. Nerve and Brachial Plexus Surgery Unit, Mont-Louis Private Hospital, 8 rue de la Folie-Regnault, 75011, Paris, France

    Christophe Oberlin & Zoubir Belkheyar

Authors
  1. Laurent Mathieu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Melody Goncalves
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. James Charles Murison
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Georges Pfister
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Christophe Oberlin
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Zoubir Belkheyar
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Laurent Mathieu.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mathieu, L., Goncalves, M., Murison, J.C. et al. Ballistic peripheral nerve injuries: basic concepts, controversies, and proposal for a management strategy. Eur J Trauma Emerg Surg 48, 3529–3539 (2022). https://doi.org/10.1007/s00068-022-01929-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00068-022-01929-8

Keywords

Search

Navigation